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John Foreyt Presentation - Global Experience in Building Sustainable Healthy Communities: Overview from USA
Citation preview
Global Experience in Building
Sustainable Healthy Communities
Overview from USA
Community Health and Wellbeing Through
Multi-Sectoral Partnerships
Blacktown NSW Australia
6 December 2011
John P Foreyt PhD
Baylor College of Medicine
Houston TX
jforeytbcmedu
Increasing prevalence of obesity
worldwide
Between 1980 amp 2008 the mean BMI
worldwide increased by 04 kgmsup2 per decade
for men and 05 kgmsup2 for women
In 2008 146 billion adults worldwide were
overweight or obese
Of these 205 million men (98) and 297
million women (138) were obese
Finucane et al Lancet 2011
Increasing prevalence of obesity in
USA
If the present trend is not halted it is projected
that by the year 2030 863 of adults in the
United States will be overweight or obese
Wang Beydoun Liang et al Obesity 2008
Sectors of Society
Arts amp Entertainment
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Law and Politics
ldquoLetrsquos Moverdquo Campaign
In the end as First Lady
this isnrsquot just a policy issue
for me This is a passion
This is my mission I am
determined to work with
folks across this country to
change the way a
generation of kids thinks
about food and nutrition
Education
National School Lunch Program
Farmersrsquo Markets
Commerce and Trade
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Increasing prevalence of obesity
worldwide
Between 1980 amp 2008 the mean BMI
worldwide increased by 04 kgmsup2 per decade
for men and 05 kgmsup2 for women
In 2008 146 billion adults worldwide were
overweight or obese
Of these 205 million men (98) and 297
million women (138) were obese
Finucane et al Lancet 2011
Increasing prevalence of obesity in
USA
If the present trend is not halted it is projected
that by the year 2030 863 of adults in the
United States will be overweight or obese
Wang Beydoun Liang et al Obesity 2008
Sectors of Society
Arts amp Entertainment
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Law and Politics
ldquoLetrsquos Moverdquo Campaign
In the end as First Lady
this isnrsquot just a policy issue
for me This is a passion
This is my mission I am
determined to work with
folks across this country to
change the way a
generation of kids thinks
about food and nutrition
Education
National School Lunch Program
Farmersrsquo Markets
Commerce and Trade
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Increasing prevalence of obesity in
USA
If the present trend is not halted it is projected
that by the year 2030 863 of adults in the
United States will be overweight or obese
Wang Beydoun Liang et al Obesity 2008
Sectors of Society
Arts amp Entertainment
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Law and Politics
ldquoLetrsquos Moverdquo Campaign
In the end as First Lady
this isnrsquot just a policy issue
for me This is a passion
This is my mission I am
determined to work with
folks across this country to
change the way a
generation of kids thinks
about food and nutrition
Education
National School Lunch Program
Farmersrsquo Markets
Commerce and Trade
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Sectors of Society
Arts amp Entertainment
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Law and Politics
ldquoLetrsquos Moverdquo Campaign
In the end as First Lady
this isnrsquot just a policy issue
for me This is a passion
This is my mission I am
determined to work with
folks across this country to
change the way a
generation of kids thinks
about food and nutrition
Education
National School Lunch Program
Farmersrsquo Markets
Commerce and Trade
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Law and Politics
ldquoLetrsquos Moverdquo Campaign
In the end as First Lady
this isnrsquot just a policy issue
for me This is a passion
This is my mission I am
determined to work with
folks across this country to
change the way a
generation of kids thinks
about food and nutrition
Education
National School Lunch Program
Farmersrsquo Markets
Commerce and Trade
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Education
National School Lunch Program
Farmersrsquo Markets
Commerce and Trade
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Farmersrsquo Markets
Commerce and Trade
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Science amp Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Arts and Entertainment
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Walking School
BusKids used to walk to school all the time Whatley says Now its almost impossible And with childhood obesity rates on the rise Whatley says walking is important because its the easiest way to exercise for a lifetime
FamilyCommunity
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Health Care
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Results of Lifestyle Interventions for
Weight Loss
ldquoThose who complete weight-loss programs lose approximately 10 of their body weight only to regain two-thirds of it back within one year and almost all of it back within 5 yearsrdquo
Institute of Medicine Weighing the options Criteria for evaluating
weight management programs 1995
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Weekly group sessions over 4 ndash 6 months
Mean post-treatment weight reductions of ~ 8-10
Attrition rates are high at 2-yrs (mean = 39 range 20-65)
Attrition rates beyond 2-yrs (mean = 65)
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions for
Weight Loss
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Results of Lifestyle Interventions
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral interventions show a reliable pattern of gradual regaining of lost weight
Long-term losses of ge 5 Kg are sustained in less than 20 of patients in behavioral treatment
Perri Foreyt amp Anton Preventing Weight
Regain After Weight Loss 2008
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Results of Lifestyle Interventions
Pattern of Weight Regain
ldquoThe difficulty associated with
maintaining lost weight appears to
be the result of physiological
environmental and psychological
factors that combine to facilitate a
regaining of lost weight and an
abandonment of weight control
effortsrdquo
Perri Foreyt amp Anton 2008
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Population-wide prevention of obesity
Small changes in diet and physical activity may make more sense than focusing on large behavioral changes
By cutting 100 calories a day adults can prevent weight gain
Hill et al Science 2003 Hill AJCN 2009
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
BENEFITS OF MODEST WEIGHT LOSS
ldquoSeveral studies demonstrate that small losseshelliphelp reduce obesity-related co-morbidities and that improvements in these risk factors persist with maintenance of these modest weight lossesrdquo
Institute of Medicine 1995
- Glucose levels - HDL cholesterol levels
- Insulin levels - LDL cholesterol levels
- Glycated hemoglobin - Blood pressure
- Triglyceride levels - Quality of life levels
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Stigmatization amp Discrimination
Societal beliefs that weight can be controlled thereby suggestive of character deficits (lack of willpower laziness and emotional problems)
Negative attitudes
ldquoLast safe prejudicerdquo in US society
Rand CSW Macgregor AMC South Med J 1990
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
DISCRIMINATION
THE PAIN OF OBESITY
Former severely obese patients
100 preferred to be deaf dyslexic
diabetic or have heart disease or bad
acne than to be obese again
Leg amputation was preferred by
915 and blindness by 894
100 preferred to be a normal weight
person rather than a severely obese
multi-millionaire Rand CSW Macgregor AMC Int J Obes 199115577ndash579
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Psychosocial Burden of Obesity
Obese individuals often feel misunderstood neglected and rejected
Obese individuals have low employment prospects and are denied educational vocational and advancement opportunities
Significantly poorer quality of life
van Hout GCM van Oudheusden I amp van Heck GL Obes Surg 2004
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
A Healthy Lifestyle is All About
Balance
Healthy Diet
Healthy Physical Activity
Building Sustainable Healthy
Communities
Healthy Lifestyle
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Building Sustainable Healthy
Communities
Healthy Lifestyle
UNFORTUNATELYhellip
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Big Texan Steak Ranch
Amarillo Texas
72-oz Steak FREE if eaten within 1 hour
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
AVERAGE ADULT AMERICAN MAN
Height 5rsquo 8rdquo
Weight 195 lbs
Waist 397 in
BMI 284
CDC 2011
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
AVERAGE ADULT AMERICAN WOMAN
Height 5rsquo3rdquo
Weight 165 lbs
Waist 370 in
BMI 261
CDC 2011
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Miss America
2008
Kirsten Haglund
BMI 1629
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Eliana Ramos
Age 18
Height 5rsquo9rdquo
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
29th OLYMPIAD
BEIJING CHINA
US wrestling team captain Daniel
Cormier (2115 lbs) hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete)
US boxer Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete)
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
29th OLYMPIAD
BEIJING CHINA
Michael Phelps
8 Gold Medals SwimmingAge 23
Height 6rsquo4rdquo
Weight 195 lbs
BMI 2374
Daily Food Intake 10375 KCAL
(15 PRO 58 CHO 27 FAT)
Exercise 30 hrswk
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
2005 USDA FOOD PYRAMID
ldquoThe food pyramid
is too complicated
and has too many
messagesrdquo
Robert Post PhD USDA Deputy
Director 2011
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
2005 USDA FOOD PYRAMID
ldquoItrsquos going to be hard not to do
better than the current pyramid
which basically conveys no
useful informationrdquo
Walter C Willett MD
Chairman Department of Nutrition
Harvard School of Public Health
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
2011 USDA MY PLATE
ldquoWe are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
informationrdquo
Michelle Obama 2011
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Dietary Guidelines for Americans
2010 Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans 2010
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Efficacy-based comparative dietary guidelines
Carb Fat Pro
Mediterranean Diet 45-55 25-35 20
IOM Dietary Ref Intakes 45-65 25-35 15
NCEP-ATPIII 50-60 25-35 15
Am Dietetic Assoc 45-65 20-35 15
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
PARADOX OF INCREASING OBESITY
PREVALENCE
bull Focus on healthy eating and physical
activity
bull Awareness of dangers of obesity buthellip
bull Obesity prevalence continues to rise
bull Work amp commuting demands
bull Little time to exercise
bull Little time to prepare food
bull Availability of high-fatcalorie foods
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Rationale for community-based interventions
bull Increases in obesity prevalence due to genes
bull Increased calories (eg 200 Kcalday
over 10 years)
bull Increased portion sizes (eg 22 oz
steaks and 44 oz sodas)
bull Western diets in developing nations
increase risk of obesity
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
READINESS TO CHANGE
ldquoHabit is habit and not to be
flung out of the window but
coaxed downstairs a step at a
timerdquo
Mark Twain
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Long-Term Weight Maintenance
National Weight Control Registry (N=10000)
Survey of 3000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs Average weight loss=69
lbs
At 5 years participants had maintained an average
weight loss=52 lbs
At 10 years participants had maintained an average
weight loss=51 lbs
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Track their food intake
Count calories or fat grams
Follow a low-calorie low fat diet (1800 caloriesday
less than 30 of calories from fat
Eat breakfast regularly
Limit the amount they eat out (about 3 timesweek
eat fast food less than onceweek)
Thomas Bond Phelan et al TOS 2011
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Long-Term Weight Maintenance
Weight Maintainers report that they usually
Eat similar food regularly
Donrsquot splurge much on holidays amp special occasions
Walk about one hourday
Watch less than 10 hours of TV a week
Weigh themselves at least once a week
Thomas Bond Phelan et al TOS 2011
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al Obesity 2006 14 710-716
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
LONG-TERM WEIGHT MAINTENANCE
Daily weighing improved
maintenance of weight loss
particularly when delivered
face to face
Wing et al NEJM 2006 3551563-1571
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Most Promising Strategies For
Preventing Weight Regain
Providing multi-component
programs with ongoing
professional contacts
Physical activityexercise
Portion controlmeal replacements
Extending treatment through
weekly or bi-weekly sessions
Pharmacotherapy
Perri Foreyt amp Anton Preventing Weight Regain After Weight Loss 2008
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach focused
on reasonable long-term objectives
appears appropriate for most
patients
Perri Foreyt amp Anton Preventing Weight Regain After Weight
Loss 2008
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
An Example of a successful long-term
intervention
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
bull Action for HEAlth in Diabetes
bull Objective to examine in overweight
persons with Type 2 Diabetes the long-
term effects of an intensive lifestyle
intervention program compared to
diabetes education and support
bull 16 Centers
bull 5145 overweight volunteers with
diabetes
Look AHEAD
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Look AHEAD
Primary End Point Composite
bull Cardiovascular death (including fatal
myocardial infarction and stroke)
bull Non-fatal myocardial infarction
bull Non-fatal stroke
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Winston-Salem
Baltimore
Philadelphia
New York
Providence
Boston
Clinical Site Coordinating Center
Clinical Sites
Seattle
Los Angeles
San AntonioHouston
Baton Rouge
Minneapolis
Memphis
Birmingham
Pittsburgh
Denver
Phoenix
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Look AHEADParticipants
101100Baseline weight (kg)
589586Age (years)
9496Attended 1 year exam
360359Baseline BMI
1514Insulin Users
3737Minority
6059Women
(N=2574)(N=2630)
DSELifestyle
p lt 0004
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Look AHEAD
Study Interventions
bull Diabetes support and education - DSE (control group)
bull Lifestyle intervention ndash ILI (treatment group)
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Look AHEAD
Lifestyle Intervention
Goals
bull 7 weight loss for the group (10
for individual)
bull 175 minutes of moderate intensity
activity
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Look AHEAD
Lifestyle Intervention
bull Diet
ndash ADA NCEP (lt 30 fat lt 10 sat fat
gt15 protein)
ndash 1200-1500 (if weight lt250lbs)
ndash 1500-1800 (if weight gt250lbs)
ndash During first 4 weeks to 4 months portion
control (liquid meal replacements or
structured meal plan)
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Look AHEAD
Lifestyle Intervention
bull Physical Activity
ndash unsupervised
ndash 175 minutes moderate intensityweek
ndash 5 daysweek
ndash walking
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Weight Loss at 1-Year
-9
ILI 0
-1
-2
-3
-4
-5
-6
-7
-8
DSE
p lt 00001
W
eig
ht
Chan
ge
86
07
The Look AHEAD Research Group Diabetes Care 2007
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Reduction in Initial Weight by Gender
N=872
N=1229N=1197
N=830
-12
-10
-8
-6
-4
-2
0
0 2 4 6 8 10 12
Months
R
ed
uctio
n in
In
itia
l W
eig
ht
Men
Women
Plt0001
The Look AHEAD Research Group Diabetes Care 2007
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Fitness Change () at 1-Year
0
5
10
15
20
25
Mean
Fitness C
hange
Unadjusted
Plt0001Adjusted for 1 Year
Weight Change Plt0001
58
209
108
159
DSE ILI ILIDSE
The Look AHEAD Research Group Diabetes Care 2007
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c () BL
Hemoglobin A1c () Y1
Y1 ndash Baseline
725
661
-064
729
715
-014
026
lt0001
lt0001
Fasting glucose (mgdl) BL
Fasting glucose (mgdl) Y1
Y1 ndash Baseline
1519
1304
-215
1536
1464
-72
021
lt0001
lt0001
Diabetes medications BL
Diabetes medications Y1
Y1 ndash Baseline
865
786
-78
865
887
22
093
lt0001
lt0001
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
1-Year Changes in Markers of
Blood Pressure ControlMarkers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg) BL
Systolic BP (mmHg) Y1
Y1 ndash Baseline
1282
1214
-68
1294
1266
-28
026
lt0001
lt0001
Diastolic BP (mmHg) BL
Diastolic BP (mmHg) Y1
Y1 ndash Baseline
699
670
-30
704
686
-18
011
lt0001
lt0001
Antihypertensive medications BL
Antihypertensive medications Y1
Y1 ndash Baseline
753
752
-01
737
759
22
023
054
002
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mgdl) BL
LDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
1122
1070
-52
1124
1067
-57
078
074
049
HDL-cholesterol (mgdl) BL
HDL-cholesterol (mgdl) Y1
Y1 ndash Baseline
435
469
34
436
449
14
080
lt0001
lt0001
Triglycerides (mgdl) BL
Triglycerides (mgdl) Y1
Y1 ndash Baseline
1828
1525
-303
1800
1654
-146
038
lt0001
lt0001
Lipid lowering medications BL
Lipid lowering medications Y1
Y1 ndash Baseline
494
530
37
484
578
94
052
lt0001
lt0001
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c lt 7 BL
Hemoglobin A1c lt 7 Y1
Y1 ndash Baseline
463
727
264
454
508
54
050
lt0001
lt0001
Blood pressure lt 13080 mmHg BL
Blood pressure lt 13080 mmHg Y1
Y1 ndash Baseline
535
686
151
499
570
70
001
lt0001
lt0001
LDL-cholesterol lt 100 mgdl BL
LDL-cholesterol lt 100 mgdl Y1
Y1 ndash Baseline
371
438
67
369
449
80
087
045
034
All three goals BL
All three goals Y1
Y1 ndash Baseline
108
236
128
95
160
65
013
lt0001
lt0001
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Mean Changes in Weight Fitness amp BP
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
Weight Loss
( initial wt)
-088 -615 lt 00001
Fitness
( METS)
196 1274 lt00001
HbA1c -009 -036 lt 00001
SBP (mm Hg) -297 -533 lt 00001
DBP (mm Hg) -248 -292 0012
Look AHEAD Research Group Arch Int Med 2010
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Mean Changes in Lipid Profile
Averaged Over Four Years
DSE
Mean
ILI
Mean
P-value
HDL (mgdl) 197 367 lt00001
TG (mgdl) -1975 -2556 00006
LDL (mgdl) -1284 -1127 0009
LDL (mgdl)
(Adjusting for
medication use)
-922 -875 042
Look AHEAD Research Group Arch Int Med 2010
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Percent () Completing Outcome
Measures at Years 1-4
Intervention Group
(ILI)
Year 1 971
Year 2 949
Year 3 940
Year 4 941
Comparison Group
(DSE)
Year 1 957
Year 2 935
Year 3 938
Year 4 931
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Look AHEAD Summary
ILI had significantly greater improvements than DSE in all CVD risk factors averaged across 4 years (except LDL-C)
There may be long-term beneficial effects from this 4-year period in which ILI subjects have been exposed to lower CVD risk factors
Longer follow-ups will determine whether these lowered CVD risk factors can be maintained amp whether lifestyle intervention has positive effects on CVD morbidity amp mortality
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Mary J
Female
White
56 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight diverticulosis arthritis
sleep apnea back pain
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Mary J
bullLong term strugglesbull Helping youngest daughter with
personal issues and children
bull Rotator cuff problems
bull Degenerative disks in back
bull Rheumatoid arthritis
bull Diabetes
bull Physically demanding job
bull Financial struggles
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Pounds
Years
82007 grandkids enter pre-school
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Catherine L
Female
White
47 years old at start of Look AHEAD
study
Past Medical History Type 2 diabetes
overweight high blood pressure
hypothyroidism back pain
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Catherine L
Long term struggles
bull Motherrsquos declining health and death
bull Multiple serious injuries
bull Sudden death of sister
bull Death of step-father
bull Declining economy
bull Children living at home
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Pounds
Years
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Realistic Management Goals
5-10 weight loss
Health energy and fitness
Well-being and self-esteem
Mood and appearance
Functional and recreational
activity
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Strategies for Building
Sustainable Healthy Communities
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children amp youth
Create safe communities that support physical
activity
Encourage communities to organize for change
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Increase the availability of healthier food and
beverage choices in public service venues (eg
schools city amp county buildings etc)
--Insufficient evidence in school-based programs
--Associations suggest availability amp increased
consumption
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve availability of affordable healthier
food amp beverage choices in public service
venues
--Reducing the cost of healthier foods
increases their purchase
--Providing coupons redeemable for
healthier foods increases their purchase
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Improve geographic availability of
supermarkets in underserved areas
-- Greater access to nearby supermarkets is
associated with healthier eating behaviors
-- Increasing the number of supermarkets in
underserved neighborhoods increased
real estate values increased economic
activity amp employment amp resulted in lower
food prices
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Promote the Availability of Affordable
Healthy Food and Beverages
Provide incentives to food retailers to locate in
andor offer healthier food choices in
underserved areas
-- Presence of retail venues that provide healthier
foods is associated with better nutrition
-- Greater availability of supermarkets was
associated with lower adolescent BMI scores
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Improve availability of mechanisms for
purchasing foods from farms
--Evidence supporting a direct link between
purchasing food from farms amp improved diet is
limited
--Two studies of initiatives to encourage
participation in farmersrsquo market showed
increased intention to eat more fruits amp
vegetables but no direct evidence
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Promote the Availability of Affordable Healthy
Food and Beverages
Provide incentives for the production
distribution and procurement of foods from local
farms
--No evidence has been published to link local
food production amp health outcomes
--There is a current study exploring the potential
nutritional amp health benefits of eating locally
grown foods
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Restrict availability of less healthy foods amp
beverages in public service venues
--No peer-reviewed studies examined the impact
designed to restrict availability of less healthy
foods in public service venues
--21 states have policies that restrict the sale of
competitive foods in schools beyond USDA
regulations however no studies have evaluated
the impact of the policies
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Institute smaller portion size options in public
service venues
--Evidence is lacking to demonstrate effectiveness
of population-based interventions aimed at
reducing portion sizes in public service venues
--Evidence from clinical studies in laboratories
demonstrates decreasing portion sizes
decreases energy intake
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Limit advertisements of less healthy foods amp
beverages
--Little evidence is available regarding the impact
of restricting advertising on purchasing amp
consumption of less healthy foods
--Cross-sectional time-series studies of tobacco-
control efforts suggest an association between
advertising bans amp decreased tobacco
consumption
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to Support Healthy Food and Beverage Choices
Discourage consumption of sugar-sweetened
beverages
--One longitudinal study of a school-based
intervention among Native-American high school
students showed a substantial reduction in
sugar-sweetened beverages over a 3-year
period
--A RCT of a home-based intervention that
eliminated sugar-sweetened beverages showed
reduction in BMI scores
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to encourage breastfeeding
Increase support for breastfeeding
--Evidence directly linking environmental
interventions that support breastfeeding with
obesity-related outcomes is lacking
--Epidemiologic studies indicate that breastfeeding
helps prevent pediatric obesity
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Require physical education in schools
--14 studies have demonstrated that school-based
PE was effective in increasing levels of physical
activity and improving physical fitness
--Minimum of 150 minwk in elementary schools
225 minwk in middle schools and high schools
throughout the school year as recommended by
NASPE
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Increase opportunities for extracurricular
physical activity
--Participation in after-school programs increased
studentsrsquo level of physical activity amp improved
obesity-related outcomes (improved CV fitness
reduced body fat)
--2 pilot studies providing extracurricular physical
activity showed increased levels of PA amp
decreased sedentary behavior
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to encourage physical activity or limit sedentary
activity among children and youth
Reduce screen time in public service venues
--A school-based RCT indicated that children who
reduced their television videotape amp video
game use had significant decrease in BMI tricep
skin fold thickness amp waist circumference
compared to controls
--Spending less time watching television is
associated with increased physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Improve access to outdoor recreational
facilities
--Review of 108 studies indicated that access to facilities
and programs for recreation near their homes amp time
spent outdoors correlated positively with increased
physical activity among childrenamp adults
--Perceptions that footpaths are safe for walking was
significantly associated with adults being classified as
physically active at a level sufficient for health benefits
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting
bicycling
--Longitudinal intervention studies have
demonstrated that improving bicycling
infrastructure is associated with increased
frequency of bicycling
--Cross-sectional studies indicated a significant
association between bicycling infrastructure amp
frequency of biking
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Enhance infrastructure supporting walking
--Reviews of cross-sectional studies of
environmental correlates of physical activity amp
walking generally find a positive association
between infrastructure supportive of walking amp
physical activity
--Identifying amp creating safe routes to school
together with educational components
increased the number of students walking to
school
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Locating schools within easy walking
distance of residential areas
--Community-scale urban design amp land use policies amp
practices including locating schools stores workplaces
amp recreation areas close to residential areas are
effective in facilitating an increase in levels of physical
activity
--Majority of efforts to encourage walking to school involve
improving the routes rather than improving the location
of schools
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support
physical activity
Improve access to public transportation
--Insufficient evidence exists to determine
effectiveness of transportation policies in
increasing the level of physical activity or
improving fitness
--1 study indicated that 29 of individuals who
walk to and from public transit achieve at least
30 minutes of daily physical activity
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Zone for mixed-use development
--Allows residential commercial institutional amp
other public land uses to be located in close
proximity to one another
--Studies using correlation analyses amp regression
models indicated that mixed land use was
associated with increased walking amp cycling
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance personal safety in areas where
persons are or could be physically active
--Cross-sectional studies have demonstrated a
negative relationship between crime rates andor
perceived safety amp physical activity in
neighborhoods
--Few intervention studies have evaluated the
impact of policies amp practices to improve
personal safety on physical activity
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Geospatial Mapping Linking Urban
Environments to Health Risk
Measure association between environmental variables amp health risk factors
Assess relationships between variables at different levels of analysis
Used in conjunction with linear analyses
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Our Community Environmental Model
of Obesity
Community Factors
Poverty
Crime
Grocery Quality
Restaurants
Parks
Sidewalks
Fast Food Outlets
Recreational
Facilities
Individual Factors
Dietary Intake
Physical Activity
Genetics
Family History
StressCoping
Eating Disorders
Psychological
Problems
Weight
Status
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Chosen Neighborhoods
Census-block groups in the metro Kansas City area (Missouri) were identified based on a median income split (ie low and high income) and mapped
We then matched census-block groups within the income groups by population density and percentage of minority representation
One matched block group per income level was randomly selected
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Prevalence of Obesity in
Block-Groups
0
5
10
15
20
25
30
35
40
45
50
Ag
e-a
dju
sted
Ob
esit
y P
rev
ale
nce
(
)
High-Income Low-Income
Age-standardized to the 1990 US Census
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Density of Environmental Factors in the
Community Contributes to a ldquoToxicrdquo
Obesity Environment
0
2
4
6
8
10
12
14
16
18
Fast-food Convenience Store Bars
Den
sity
10
00
perso
ns
High-Income Low-Income
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
COMMUNITYrsquoS PERCEPTION OF SAFETY
0
5
10
15
20
25
30
35
40
Daytime Nighttime
Perc
en
t (
) F
eeli
ng
So
mew
hat
Safe
or
Un
safe
Low-Income High-Income
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
0
10
20
30
Structural Grounds
Perc
en
t (
)
Low-Income High-Income
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
From 1994-1998 HUD randomly assigned
4498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract (2)
unrestricted vouchers or (3) control group
(no vouchers)
Ludwig et al NEJM 201136516
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Neighborhoods Obesity and Diabetes
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity amp diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers amp the control group
ldquoNeighborhoods matterrdquo
Ludwig et al NEJM 201136516
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Strategies to create safe communities that support physical
activity
Enhance traffic safety in areas where
persons are or could be physically active
--Community-scale urban design amp land use policies to
promote physical activity including design components
to improve street lighting infrastructure projects to
increase safety of pedestrian street crossing and use of
traffic calming approaches such as speed humps amp
traffic circles are effective in increasing physical activity
--Both community-scale amp street-scale policies amp practices
are effective in increasing physical activity
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Recommended Community Strategies Encourage Communities to Organize for Change
Participate in community coalitions or
partnerships to address obesity
--Little evidence is available to determine the
impact of community coalitions on obesity
prevention
--The presence of anti-smoking community
coalitions has been associated with lower rates
of tobacco consumption
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities including state amp local government
agencies tribes amp territories amp state amp local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health amp wellness
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Priority areas are
Tobacco-free living
Active living and healthy eating
Evidence-based quality clinical and other
preventive health services for prevention
and control of high blood pressure and
high cholesterol
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
wwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Capacity-Building Award
The Confederated Tribes of The Chehalis
Reservation is receiving a $498663 planning
award to build capacity to support healthy
lifestyles among their tribal population of 1500
in Washington State
Work will target tobacco-free living active living
and healthy eating and quality clinical and other
healthy serviceswwwcdcgov1052011
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
What is the US Government doing
Community Transformation Grants (CTG) to
States and Communities
Example of Implementation Award
Austin TX Dept of Health and Human Services
is receiving $1026158 to serve Travis County
(Austin) to expand efforts in tobacco-free living
active living and healthy eating quality clinical
and other preventive services social and
emotional wellness and healthy and safe
physical environmentswwwcdcgov1052011
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Building sustainable healthy
communities Bottom line
Obesity is an environmental problem
Despite progress in genetic research public health advances only will occur when we take the environment seriously
Acknowledging the role of the environment in the etiology of obesity will help us stop focusing on the individual which is encouraged by genetic and biological explanations and begin focusing on changing the toxic environment
Until we do this we will not make substantial progress in addressing the epidemic of obesity
Poston amp Foreyt Atherosclerosis 1999
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Whatrsquos the best approach
Integrate all sectors of society into community
change interventions
Incorporate
Science amp Technology
Education
FamilyCommunity
Healthcare
Arts amp Entertainment
Law amp Politics
Commerce amp Trade
Sectors of Society
Arts amp Entertainm
ent
Commerce amp Trade
Education
FamilyCommunity
Healthcare
Law amp Politics
Science amp Technology
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
Project FIT rationale design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary school children
Eisenmann JC Alaimo K Pfeiffer K Paek HJ Carlson JJ Hayes H Thompson T Kelleher D
Oh HJ Orth J Randall S Mayfield K Holmes D
Source
Department of Kinesiology Michigan State University East Lansing MI USA jcemsuedu
Abstract
BACKGROUND
This paper describes Project FIT a collaboration between the public school system local
health systems physicians neighborhood associations businesses faith-based leaders
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids MI USA
METHODSDESIGN
There are four overall components to Project FIT school community social marketing and
school staff wellness - all that focus on 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools 3) improving the knowledge self-efficacy attitudes and behaviors regarding
nutrition and physical activity among school staff parents and students 4) impacting the
culture of the schools and neighborhoods to incorporate healthful values and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
ldquoThe Current Epidemics of Chronic Diseases
are a Result of Discordance Between Our
Ancient Genes and Modern Lifestylerdquo
Eaton et al The Paleolithic Prescription 1988
Building sustainable healthy
communities
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
ldquoAccuse not nature
She has done her part
Do Thou but Thinerdquo
John Milton (1687) Paradise Lost
Building sustainable healthy
communities
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up
SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up