Planet Health: The Prevention of Childhood and Adolescent Obesity Through School-Based Intervention

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Planet Health The Prevention of Childhood and
Adolescent Obesity Through School-Based
Intervention

• Steven Gortmaker, Ph.D.
• Harvard School of Public Health /Harvard
  Prevention Research Center
• Talk at MCH Epi Conference December 2006

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Overview

• Strategies to prevent obesity in Planet Health
  2nd Edition (in press)
• Reduce sugar sweetened beverages, fast food,
  unhealthy fat, TV
• Increase fruits and vegetables, physical activity
• Planet Health interdisciplinary curriculum
• Effectiveness and cost-effectiveness
• Dissemination Teachers and students like it!
• Translation to Life course Impact Thinking
  Outside the School

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Causes of the Overweight Epidemic The Science of
Energy Balance

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Obesity Fundamentals

• Obesity is caused by Energy Intake in excess of
  Energy Expenditure
• The daily energy imbalance driving the epidemic
  is on average small - an extra sugar sweetened
  beverage per day but greater for obese youth.
• Social context is important (e.g. sodas
  everywhere)

Koplan JP,Dietz WH. Caloric imbalance and public
health policy. JAMA. 19992821579-81. Wang YC,
Gortmaker SL, Sobol AM, Kuntz KM. Estimating the
energy gap among U.S. children A counterfactual
approach. Pediatrics, Dec 2006.
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The Important Forces

• Food producers and the "Fast Food" industry -
  if theyre successful, we all eat more
• Advertisers for food and video/film
  industries - if theyre successful, we all buy
  more
• Television and video/film production and
  distribution industry - if theyre successful
  we all watch more

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Sugar-sweetened beverages contribute to childhood
obesity incidence

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An extra can of sugar sweetened beverage per day
(150 kcal) can lead to an excess of 5 pounds per
year body weight
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Trends in Beverage Consumption Among US
Adolescents, USDA 1965-96 Cavadini et al. Arch
Dis Child 2000
Boys
Girls
Consumption (ml/d)
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Soft Drink Consumption and Overweight
For each additional serving of sugar-sweetened
beverage consumed, both BMI (0.243 kg/m2
P0.03), and incidence of obesity (odds ratio
1.60 P0.02) increased.
Ludwig DS, Peterson KE, Gortmaker SL. Lancet
2001, 357505-8
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Reducing Intake of Sugar Sweetened Beverages Can
Reduce Overweight Among Youth
A school-based randomized controlled intervention
found that intake of carbonated drinks could be
decreased, and that this change was accompanied
by a decrease in percentage of overweight and
obese children (-7.7 95 confidence interval
2.2 to 13.1)
James J, et al. BMJ 27 April 2004.
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Sugar Sweetened Beverage Consumption and Weight
Gain and Diabetes Incidence in Adult Women
women consuming 1 or more sugar-sweetened soft
drinks per day had a relative risk of type 2
diabetes of 1.80 Plt0.001 for trend) compared
with those who consumed less than 1 of these
beverages per month.
Schulze et al. JAMA 2004, 292927-34.
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The growth of the fast food industry and
increasing portion sizes make it easy for
children to overeat

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A large fast food meal (double cheeseburger,
french fries, soft drink, desert) could contain
2200 kcal, which would require a full marathon
to burn off
Ebbeling CB, Pawlak DB, Ludwig DS. Childhood
obesity public health crisis, common sense
cure. Lancet 2002360473-82.
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First picture from the surface of Mars
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Austin SB, Melly SJ, Sanchez BN, Patel A, Buka S,
Gortmaker SL. Clustering of fast food
restaurants around schools a novel application
of spatial statistics to the study of food
environments. American Journal of Public Health,
2005 Sep95(9)1575-81 .
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Fast Food and Diet of Children and Youth

• On days that children and youth eat fast food
  they consume an extra 126 kcals/day (Plt0.0001)
• Higher income children, non-Hispanic African
  Americans, and children in the South eat more
  fast food

Bowman S, Gortmaker SL, Ebbeling CB, Pereira MA,
Ludwig DS. Effects of fast food consumption on
energy intake and diet quality among children in
a national household survey. Pediatrics,
Pediatrics. 2004 Jan113(1 Pt 1)112-8.
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The Important Forces

• Food producers and the "Fast Food" industry -
  if theyre successful, we all eat more
• Advertisers for food and video/film
  industries - if theyre successful, we all buy
  more
• Television and video/film production and
  distribution industry - if theyre successful
  we all watch more

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Television Viewing and Energy Balance The Science

• How can television viewing cause obesity?
• Evidence in support of hypothesis

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Hypothesized Impact of Television Viewing on
Obesity
Dietary Intake
Obesity
Television Viewing
Inactivity
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Dietz WH, Gortmaker SL.  Do we fatten our
children at the tv set?  Obesity and television
viewing in children and adolescents. Pediatrics,
1985 75807-812. Gortmaker SL, Must A, Sobol AM,
Peterson K, Colditz GA, Dietz WH. Television
viewing as a cause of increasing obesity among
children in the United States, 1986-1990.
Archives of Pediatrics and Adolescent Medicine,
1996150356-362.
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children currently view as many as 40,000
commercials on television and cable per year.
Finding Children are exposed to extensive
advertising for high-calorie and low-nutrient
foods and beverages and very limited advertising
of healthful foods and beverages during their
daily television viewing.
J. Michael McGinnis, Jennifer Appleton Gootman,
Vivica I. Kraak, Editors. Food Marketing to
Children and Youth Threat or Opportunity?
Institute of Medicine of the National Academies.
The National Academies Press. Washington, D.C.
2006.
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Television Viewing and Total Energy Intake A
Longitudinal Observational Study

• For each hour increase in television viewing,
  total energy intake increases 167 calories per
  day (Plt0.0001)

Wiecha JL, Peterson KE, Ludwig DS, Kim J, Sobol
A. When children eat what they watch impact of
television viewing on dietary intake in youth.
Archives of Pediatrics and Adolescent Medicine,
2006 Apr160(4)436-42 .
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Randomized Controlled Trials Television and
Obesity

• School-based intervention primary grades impact
  on mean BMI (Robinson. JAMA.1999. )
• Clinical Intervention Obese children and youth
  impact of reducing inactivity on overweight
  (Epstein et al. Health Psychol. 1995.)
• School-based intervention Planet Health
  reduced television predicts reduced obesity among
  middle school girls (Gortmaker et al. Arch
  Pediatr Adolesc Med. 1999)

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Planet Health

• An Interdisciplinary curriculum for 6th-8th grade
  students

Carter J, Wiecha J, Peterson KE, Gortmaker SL.
Planet Health. Champaign, Illinois Human
Kinetics Press, 2001.
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Goals in Creating Planet Health

• Create an interdisciplinary curriculum for middle
  schools that
• Uses existing teachers
• Reduces obesity risk by improving nutrition and
  activity and reducing screen time
• Is liked by teachers and students
• Strategy Reducing risk based on science

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Working with Schools

• Most children and youth are in schools
• Schools are major settings for learning, physical
  activity, dietary intake
• A caveat strategies must be compatible with the
  primary educational aims of schools

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Planet Health Promotes...
Literacy Across the Curriculum
Active Learning
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Behavioral Targets

• Reduce TV viewing to less than two hours per day
• Decrease consumption of high fat/saturated
  fat/trans fat foods
• Increase moderate and vigorous activity
• Increase consumption of fruits and vegetables to
  five-a-day or more

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Intervention Components

• Teacher training workshops
• Classroom lessons (16/year) in Math, Science,
  Language Arts, Social Studies
• Two-week TV reduction campaign
• Physical Education Micro-units (30 five minute
  units) and Fit-checks
• Wellness sessions for teachers (3)

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Effects of Planet Health

• Obesity among females in intervention schools was
  reduced compared to controls (OR 0.48 P0.03)
• Reductions in TV both boys girls
• Among girls, each hour of TV gt reduced obesity
  (OR 0.86/hour P0.02)
• Increases in fruit and vegetable intake and less
  increment in total energy intake among girls
  (P0.003 and P0.05)
• Gortmaker SL, Peterson K, Wiecha J, Sobol AM,
  Dixit S, Fox MK, Laird N. Reducing obesity via a
  school-based interdisciplinary intervention among
  youth Planet Health. Archives of Pediatrics and
  Adolescent Medicine. 1999153409-18.

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Intervention Impact by School

• Females evidence for intervention impact in 4 of
  5 schools. If the one ineffective site is
  dropped, intervention effect on obesity is OR
  0.31 P0.0002
• Males if the same school is dropped,
  intervention effect on obesity is OR 0.70 P0.05
  

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Change in Obesity by Ethnic Group

• Females evidence for intervention impact by
  ethnic group (minimum cell size 5)
• Afro-American (OR 0.14 95 CI 0.04-0.51)
• White (OR 0.48 95 CI 0.20-1.13)
• Hispanic (OR 0.38 95 CI 0.03-5.3)

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Impact of Planet Health on Disordered Weight
Control Behaviors Females

• girls in intervention schools were less than
  half as likely to report purging or using diet
  pills at follow-up compared with girls in control
  schools (odds ratio, 0.41 95 confidence
  interval, 0.22-0.75).

Austin SB, Field AE, Wiecha J, Peterson KE,
Gortmaker SL. The impact of a school-based
obesity prevention trial on disordered
weight-control behaviors in early adolescent
girls. Arch Pediatr Adolesc Med. 2005
Mar159(3)225-30.
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Impact of Planet Health on Delaying Menarche

• Girls attending an intervention school
  experienced menarche less frequently than girls
  attending control schools during the intervention
  period
• (RR 0.76 95 CI 0.66, 0.87.

Chavarro JE, Peterson KE, Sobol AM, Wiecha JL,
Gortmaker SL. Effects of a school-based
obesity-prevention intervention on menarche
(United States). Cancer Causes Control. 2005
Dec16(10)1245-52.
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Preventive Interventions Can be Cost-Effective

• An independent economic analysis of Planet Health
• found
• An estimated program cost of 14/student/year
• Planet Health is more cost-effective than
  commonly accepted preventive interventions, such
  as screening and treatment for hypertension.
• 4300 per QALY (quality adjusted life year)

Wang LY, Yang Q, Lowry R, Wechsler H. Economic
analysis of a school-based obesity prevention
program. Obes Res. 2003 Nov11(11)1313-24.
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Planet Health Implementation/Dissemination

• Expansion in Boston Public Schools via CDC, US
  Dept of Education, and STEPS (Boston Public
  Health Commission)
• Blue Cross Blue Shield of MA has funded a
  four-year, 3 million program for grants to
  middle schools throughout MA to implement Planet
  Health additional after school programming
• 5500 copies of Planet Health now distributed in
  48 states and 20 countries

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The Important Forces

• Food producers and the "Fast Food" industry -
  if theyre successful, we all eat more
• Advertisers for food and video/film
  industries - if theyre successful, we all buy
  more
• Television and video/film production and
  distribution industry - if theyre successful
  we all watch more

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Thinking Outside the School Life Course
Intervention Strategies (How do we get sustained
changes in reducing energy imbalance?)

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• Steven Gortmaker PhD PI
• Charles Deutsch ScD Co-PI
• Jean Wiecha PhD Co-PI
• Multiple Community Engagement Committees
• 20 other faculty and staff
• Funding Centers for Disease Control and
  Prevention

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A Broad Vision of Our Work

• Its not just individual choice - we focus on
  social ecological, behavioral, and
  transdisciplinary approaches to improving
  nutrition, physical activity, and reducing
  overweight and chronic disease in children and
  youth.
• We work with community partners to develop and
  evaluate interventions within multiple social and
  environmental settings e.g. schools,
  pre-schools, after schools, primary health care,
  worksites, neighborhoods and homes. Supportive
  change in many such environments/channels will be
  needed to halt the rise in chronic disease risk.
  

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Starting YoungPreventing Overweight in the
Head Start Setting

• Funded by Harvard Pilgrim Health Care Foundation

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Eat Well and Keep Moving
Interdisciplinary curriculum for 4th and 5th
grade Evaluation indicates improved dietary
intake (total fat, sat fat,
fruits/vegetables, vit C, dietary fiber) and
Reduced Television Viewing
Cheung PLYH, Dart H, Gortmaker SL. Eat Well and
Keep and Moving. Champaign, Illinois Human
Kinetics Press, 2001.
Gortmaker SL, Cheung LWY, Peterson KE, Chomitz G,
Cradle JH, Dart H, Fox MK, Bullock RB, Sobol AM,
Colditz G, Field A, Laird N. Archives of
Pediatrics and Adolescent Medicine
1999153975-83.
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Planet Health

• Steven Gortmaker, PhD PI
• Karen Peterson, RD, ScD Co-PI
• Jean Wiecha, PhD Project Director
• Nan Laird, PhD Co-Investigator
• Funding NICHD HD 30780

Carter J, Wiecha J, Peterson KE, Gortmaker SL.
Planet Health. Champaign, Illinois Human
Kinetics Press, 2001.
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Clinical Interventions in Primary Care Settings

• Maine Youth Overweight Collaborative (lead by
  Maine Center for Public Health Maine Health
  Access Foundation)
• Healthy Care for Healthy Kids Collaborative in
  Massachusetts (lead by with National Initiative
  for Childrens Health Care Quality (NICHQ), with
  Blue Cross Blue Shield of MA)
• High Five for Kids (lead by Department of
  Ambulatory Care and Prevention, Harvard Medical
  School (NICHD))

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ACTIVATE AMERICA
Community Leadership Strengthening YMCAs
capacity for community leadership in support of
healthy living
Strategic Partnerships Magnifying the YMCAs
impact through strategic partnerships
The Gulick Project Directly helping individuals
and families lead healthier lives
Built on a solid foundation A 150 year
commitment to health in spirit, mind, body .
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A Vision For Ending the Obesity Epidemic and
Eliminating Disparities

• We can develop interventions - grounded in
  science - that effectively provide supportive
  environments for healthy eating and physical
  activity for children (and adults)
• But unless this science is translated into action
  into the diverse lives of households and
  children and youth and via a multitude of
  channels, throughout the life course the impact
  may be trivial.