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Progress in Preventing Childhood Obesity: How Do We Measure Up


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Title: Progress in Preventing Childhood Obesity: How Do We Measure Up

Progress in Preventing Childhood Obesity How Do
We Measure Up?
  • Eduardo Sanchez, M.D., M.P.H.Director, Institute
    for Health Policy
  • University of Texas School of
  • Public Health
  • November 3, 2006

Discussion Points
  • Background
  • Obesity prevalence and related health trends
  • Conclusions
  • Elements of an effective response
  • Evaluation framework and approach
  • Recommendations
  • Next steps

  • 2004
  • Congressional request
  • Sponsors DHHS (CDC, NIH, ODPHP),
  • RWJF
  • 19-member IOM committee
  • Blueprint for comprehensive action plan
  • 2006
  • Sponsor RWJF
  • 13-member IOM committee
  • Assess progress in preventing
  • childhood obesity
  • Conduct 3 regional workshops

IOM Committee on Progress in Preventing
Childhood Obesity
  • Emory University
  • St. Louis University
  • Health and Medical Division,
  • Eastern Band of Cherokee Indians
  • California Department of Health Services
  • University of Illinois Urbana-Champaign
  • RTI International
  • Georgia State University
  • University of South Carolina
  • Procter Gamble Company
  • Georgia Division of Public Health
  • Stanford University
  • Texas Department of State Health Services
  • UCLA School of Public Health
  • Consultants
  • University of Pennsylvania
  • Texas Department of State Health Services
  • IOM Staff

IOM Regional Symposia
  • Three regional symposia
  • June 2005, Wichita, KS Focus on schools
  • October 2005, Atlanta, GA Focus on communities
  • December 2005, Irvine, CA Focus on industry
  • Discuss current and promising initiatives
  • Identify barriers and assets to sustainability
    and evaluation of interventions
  • Identify areas of convergence and next steps for
    stakeholders and sectors

  • Obesity refers to children and youth who have a
    BMI for age at or above the sex-specific 95th
    percentile of the BMI charts developed by the CDC
    in 2000.
  • At risk for obesity refers to children and youth
    BMI for age at or above the sex-specific 85th
    percentile but less than the 95th percentile of
    the CDC BMI charts.
  • In most children, BMI values 95th percentile
    indicate elevated body fat and reflect the
    presence or risk of related diseases.
  • U.S. has no BMI-for-age references for children lt
    2 years.
  • CDC uses overweight instead of obesity for
    children and youth.

National Obesity Prevalence for Children and
  • One third (33.6 percent) of 2- to 19-year olds
    are obese or at risk
  • Obesity (defined as BMI 95th percentile) for
    based on NHANES data
  • 13.9 percent in 19992000
  • 15.4 percent in 20012002
  • 17.1 percent in 20032004 (obese) 16.5 percent
    (at risk)
  • By 2010, an estimated 20 percent of U.S. children
    and youth in the United States will be obese if
    the current trajectory continues
  • Sources Ogden et al. (2006) Sondik

U.S. Obesity Epidemic Trends for Children and
Youth by Age and Time Frame, 1963-2004
Source Ogden et al., 2006
U.S. Childhood Obesity Epidemic Trends by Sex
and Race/Ethnicity, 2003-2004
Obese (BMI 95th percentile)
At Risk ( 85th percentile BMI lt 95th percentile)
At Risk Obese
Source Ogden et al., 2006
Obesity in Diverse Populations
  • NHANES 2003-2004, non-Hispanic African American
    and Mexican-American children and adolescents,
    2-19 years, have a greater obesity prevalence
    than whites.
  • Children and youth at highest risk for obesity
    often experience other social, economic, and
    health disparities concurrently and do not live
    in environments that support healthy behaviors.

Adverse Childhood Experiences (ACE) Study
  • As a follow-up, Kaiser Permanente CDC conducted
    As a follow-up, Kaiser Permanente CDC conducted
    ACE study
  • Study involved 19,000 mostly middle class, middle
    aged adults
  • Results show childhood abuse household
    dysfunction led to chronic diseases decades later
  • Traditionally viewed as public health problems,
    behaviors may also be coping mechanisms
  • ACE study
  • Study involved 19,000 mostly middle class, middle
    aged adults
  • Results show childhood abuse household
    dysfunction led to chronic diseases decades later
  • Traditionally viewed as public health problems,
    behaviors may also be coping mechanisms

Other Health Trends
  • Doubling of type 2 diabetes among children and
    youth over past decade
  • SEARCH for Diabetes in YOUTH Study (2006)
    provides population-based sample for type 1 and
    type 2 diabetes
  • Prevalence lower for children ages 0-9 years (.79
  • 10-19 year olds (2.8 cases/1,000)
  • Type 2 diabetes found in all racial/ethnic groups
    but less common than type 1 except for American
    Indian youth
  • One million 12- to 19-year-olds have the
    metabolic syndrome (3 of 5 metabolic

U.S. Adult Obesity Prevalence
  • CDC has tracked adult obesity trends in 50 states
    from 1985 to present
  • CDC Maps for U.S. Adult Obesity Trends (BRFSS),
    1985 to 2004
  • U.S. adult obesity rates
  • 2004 15-19 in 7 states, 20-24 in 33 states
    25 percent or more in 9 states
  • 2003-2005 rates exceeded 20 in 43 states DC
    (Trust for Americas Health, 2006)

Conclusions from IOM ReportHealth in the Balance
  • Childhood obesity is a serious nationwide health
    problem with multi-factorial causes requiring a
    population-based prevention approach and a
    comprehensive response.
  • The goal is energy balancehealthy eating
    behaviors and regular physical activity to
    achieve a healthy weight while protecting health
    and normal growth and development.
  • Preventing childhood obesity is a collective
    responsibilitymultiple sectors and stakeholders
    must be involved in societal changes at all

Sectors to Involve in Childhood Obesity Response
  • Government (federal, state, local)
  • Industry (food, beverage, restaurant, food
    retailers, entertainment, recreation, leisure)
  • Media (unpaid and paid)
  • Communities (nonprofits, foundations, faith-based
    groups, child- and youth-related organizations,
    health care sector)
  • Schools (e.g., preschool, after school, child
  • Home (families and care providers)

  • Government
  • Public Health
  • Health Care
  • Agriculture
  • Education
  • Media
  • Land Use and Transportation
  • Communities
  • Foundations
  • Industry
  • Food
  • Beverage
  • Retail
  • Leisure and Recreation
  • Entertainment
  • Communities
  • Worksites
  • Health Care
  • Schools and Child Care
  • Home

Social Norms and Values
Sectors of Influence
Behavioral Settings
  • Demographic Factors (e.g., age, sex, SES,
  • Psychosocial Factors
  • Gene-Environment Interactions
  • Other Factors

Individual Factors
Physical Activity
Food Beverage Intake
Energy Intake
Energy Expenditure
Energy Balance
Conclusions from IOM ReportHow Do We Measure Up?
  • Marked underinvestment in childhood obesity
    prevention interventions - current investment
    does not match extent of problem.
  • A robust evidence base is needed to identify
    promising practices so effective interventions
    can be scaled-up and supported in diverse
  • Need for collective responsibility and collective
  • Evaluation of ongoing efforts is needed -
    adequate resources need to be committed to

  • Lead and commit to childhood obesity prevention
  • Evaluate policies and programs and build
    evaluation capacity
  • Monitor progress and conduct research
  • Disseminate promising practices

Promising and Best Practices
  • Promising Practices
  • Interventions likely to reduce childhood obesity
    and have been evaluated but lack sufficient
    evidence to link it to reducing childhood obesity
    and co-morbidities
  • Promising practices always have evaluation
  • Best Practices
  • Interventions with sufficient evidence to provide
    certainty that they are linked to reducing
    childhood obesity and co-morbidities
  • Very few best practices available to guide
    childhood obesity prevention efforts

Characteristics of Effective Interventions
  • Evaluation built into interventions from the
  • Consider diverse perspectives and attend to
    community and population context
  • Link with other programs to produce synergistic
  • Include relevant outcome measures given the scope
    of intervention
  • Range of interventions across all sectors and all
    types of outcomes should be measured

Obesity Prevention Evaluation Framework
  • Sectors
  • Resources and inputs
  • Strategies and actions
  • Continuum of outcomes
  • Policy (e.g., structural, institutional,
    systemic) outcomes
  • Environmental outcomes
  • Social and cognitive outcomes
  • Behavioral outcomes
  • Health outcomes


IOM Evaluation Framework for Obesity Prevention
Policies and Interventions
  • Programs
  • Policies
  • Surveillance
  • and Monitoring
  • Education
  • Partnerships
  • Coalitions
  • Coordination
  • Collaboration
  • Communication
  • Marketing
  • and Promotion
  • Product
  • Development
  • New Technologies

Government Industry Communities Schools Home
Leadership Strategic Planning Political
Structural, Institutional, Systemic Outcomes
Health Outcomes Reduce BMI Levels in the
Population Reduce Obesity Prevalence Reduce
Obesity-Related Morbidity
Cognitive and Social Outcomes
  • Behavioral Outcomes
  • Dietary
  • Physical Activity

Adequate Funding and Capacity Development
Environmental Outcomes
Cross-Cutting Factors that Influence the
Evaluation of Policies and Interventions Age
sex socioeconomic status race and ethnicity
culture immigration status and acculturation
biobehavioral and gene-environment interactions
psychosocial status social, political, and
historical contexts.
Examples of Promising Practices Government
  • USDA and DoD Fresh Fruit and Vegetable Program
  • CDCs 5-year VERB campaign had positive
    evaluation results in promoting physical activity
    among tweens (funding discontinued in 2006).
  • CDCs Nutrition and Physical Activity Program to
    Prevent Childhood Obesity and Other Chronic
    Diseases (16 million to 28 states in 2005-06
    provided to increase capacity to implement
    programs and evaluations).
  • Federal Safe Routes to School Program (initiated
    in 2005) has evaluation underway.

Examples of Promising PracticesIndustry Media
  • Changes by food, beverage, restaurant, recreation
    and entertainment companies based on company
    market testing and consumer marketing research.
  • Companies developed new or reformulated products,
    changed packaging (100-calorie packs), expanded
    meals to help consumers adhere to DGA.
  • Most evaluations not publicly available many
    innovative interventions not evaluated.
  • Media - Small Step (PSA awareness) Coalition for
    Healthy Children (2 evaluations).

Examples of Promising Practices Communities
  • Coalitions are tracking changes in policies and
    programs to promote physical activity and expand
    access to healthier foods and beverages (built
  • HHS Steps to a Healthier US Initiative (Steps
    Program) supports 40 communities nationwide
    (35.8 million provided for FY 2004-2006) and has
    evaluation underway.
  • Community-academic partnerships
  • Public-private partnerships (implement statewide
    obesity prevention action plans GA, WV, NC, TX).

Role of Foundations
  • Many public-private partnerships involve support
    from corporate or private foundations
  • Foundations are becoming important leaders in the
    response to childhood obesity
  • Foundations have several advantages
  • Greater flexibility in their funding mechanisms
    than government agencies
  • Support to explore untested or promising
    approaches and evaluation of natural experiments
  • Important funding source for grantees at the
    community level and often require the submission
    of an evaluation plan to accompany a grant

Examples of Promising Practices Foundations
  • Corporate Foundations
  • Produce for Better Health Foundation, General
    Mills Foundation, PepsiCo Foundation, IFIC
    Foundation, Aetna Foundation
  • Private Foundations (national, regional, state)
  • W.K. Kellogg Foundation, William J. Clinton
    Foundation, California Endowment
  • Sunflower Foundation, Healthcare Georgia
    Foundation, Kansas Health Foundation
  • Robert Wood Johnson Foundation
  • Active Living by Design and Active Living
    Leadership initiatives
  • Healthy Eating Research initiative
  • Ad Councils Coalition for Healthy Children

Examples of Promising Practices Schools
  • School nutrition standards
  • Awards programs for healthy schools (e.g., Utah
    Gold Medal Schools Program)
  • Public-private partnerships
  • Alliance for a Healthier Generation has
    evaluation underway
  • After-school programs
  • CATCH Kids Club, Georgia Fit Kid Project, SPARK
  • Need to systematically evaluate school wellness
    policies as they are adopted and promoted
  • Kansas Coordinated School Health Program
  • Local school wellness policies

Examples of Promising Practices Home
  • Fit WIC, pilot-tested in 4 states in 1999,
    evaluated parents behaviors to reduce obesity in
    preschoolers. Parents who participated were more
    likely to introduce positive behaviors to their
  • Hip Hop to Health Jr., a preschool intervention
    with low-income African-American children in Head
    Start provided incentives to parents to encourage
    healthy eating behaviors and physical activity in
  • Stanfords Student Media Awareness to Reduce
    Television classroom curriculum reaches parents
    to reduce 3rd-4th graders leisure screen time.

Next Steps for Addressing the Childhood Obesity
Epidemic Government
  • Establish high-level task forces (federal, state,
    local) to identify priorities for action,
    coordinate public-sector efforts, and establish
    effective interdepartmental collaborations.
  • Provide sustained commitment and long-term
    investment in childhood obesity prevention
    initiatives and surveillance efforts.

Next Steps for Addressing the Childhood Obesity
Epidemic Industry Media
  • Support and market product innovations and
  • Independent and periodic evaluations of
    industrys efforts.
  • Develop and strengthen publicprivate
  • Share proprietary data that can expand
    understanding of consumer purchasing and
    marketing trends.
  • Evaluate progress in developing and communicating
    storylines and programming that promote healthy

Next Steps for Addressing the Childhood Obesity
Epidemic Communities
  • Develop community health index toolkit through
    governmentacademiccommunity partnerships to
    help examine factors relevant to creating
    healthy communities.
  • Expand collection and dissemination of local data
  • Compile and widely share community-based
    evaluation results, lessons learned, and
    community action plans.

Next Steps for Addressing the Childhood Obesity
Epidemic Foundations
  • Community stakeholders (including private and
    corporate foundations) should establish and
    strengthen the local policies, coalitions, and
    collaborations needed to create and sustain
    healthy communities.
  • Industry (including corporate foundations) should
    use the full range of available resources and
    tools to create, support, and sustain consumer
    demand for products and opportunities that
    support healthy lifestyles including healthful
    diets and regular physical activity.

Next Steps for Addressing the Childhood Obesity
Epidemic Foundations
  • Community stakeholders should partner with
    foundations, government agencies, faith-based
    organizations, and youth-related organizations to
    strengthen evaluation efforts at the local level
    and support community-academic partnerships.
  • Schools and school districts should partner with
    state and federal agencies, foundations, and
    academic institutions to develop, implement, and
    support evaluations of all school-based programs
    and publish and widely disseminate the evaluation
    results of school-based childhood obesity
    prevention efforts and related materials and

Next Steps for Addressing the Childhood Obesity
Epidemic Schools
  • Elevate the priority placed on sustaining a
    healthy school environment.
  • Increase resources for technical assistance to
    evaluate changes in schools (physical activity
    and diet).
  • Expand surveillance and data collection efforts
  • Compile and widely share school-based evaluation
    results and lessons learned.

Next Steps for Addressing the Childhood Obesity
Epidemic Home
  • Families should assess the home environment to
    ensure that foods and beverages supporting a
    healthful diet are consumed by children and youth
    at home and served in reasonable portion sizes.
  • Families should emphasize physical activity as a
    family priority and establish rules or guidelines
    that limit leisure screen time (e.g., television,
    DVDs, videos, movies, videogames, and computers).

For More Information
  • Fact sheets
  • Read the book online or purchase the report
  • RWJF TV Health Series