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

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

Causes of the Overweight Epidemic: The Science of Energy Balance

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. 1999;282: Wang YC, Gortmaker SL, Sobol AM, Kuntz KM. Estimating the energy gap among U.S. children: A counterfactual approach. Pediatrics, Dec 2006.

The Important Forces: F ood producers and the "Fast Food" industry - if they’re successful, we all eat more A dvertisers for food and video/film industries - if they’re successful, we all buy more T elevision and video/film production and distribution industry - if they’re successful we all watch more

Sugar-sweetened beverages contribute to childhood obesity incidence

An extra can of sugar sweetened beverage per day (150 kcal) can lead to an excess of 5 pounds per year body weight

Consumption (ml/d) Boys Girls Trends in Beverage Consumption Among US Adolescents, USDA Cavadini et al. Arch Dis Child 2000

“For each additional serving of sugar- sweetened beverage consumed, both BMI (0.243 kg/m2; P=0.03), and incidence of obesity (odds ratio 1.60; P=0.02) increased.” Ludwig DS, Peterson KE, Gortmaker SL. Lancet 2001, 357:505-8 Soft Drink Consumption and Overweight

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 Reducing Intake of Sugar Sweetened Beverages Can Reduce Overweight Among Youth

“…women consuming 1 or more sugar- sweetened soft drinks per day had a relative risk of type 2 diabetes of 1.80; P<0.001 for trend) compared with those who consumed less than 1 of these beverages per month.” Schulze et al. JAMA 2004, 292: Sugar Sweetened Beverage Consumption and Weight Gain and Diabetes Incidence in Adult Women

The growth of the fast food industry and increasing portion sizes make it easy for children to overeat

Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public health crisis, common sense cure. Lancet 2002;360: “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”

First picture from the surface of Mars

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 Sep;95(9):

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 Jan;113(1 Pt 1): Fast Food and Diet of Children and Youth On days that children and youth eat fast food – they consume an extra 126 kcals/day (P<0.0001) Higher income children, non-Hispanic African Americans, and children in the South eat more fast food

The Important Forces: F ood producers and the "Fast Food" industry - if they’re successful, we all eat more A dvertisers for food and video/film industries - if they’re successful, we all buy more T elevision and video/film production and distribution industry - if they’re successful we all watch more

Television Viewing and Energy Balance: The Science How can television viewing cause obesity? Evidence in support of hypothesis

Hypothesized Impact of Television Viewing on Obesity Obesity Television Viewing Dietary Intake Inactivity

Dietz WH, Gortmaker SL. Do we fatten our children at the tv set? Obesity and television viewing in children and adolescents. Pediatrics, 1985; 75: 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, Archives of Pediatrics and Adolescent Medicine, 1996;150:

“…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

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 (P<0.0001) 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 Apr;160(4):

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

Planet Health An Interdisciplinary curriculum for 6 th -8 th grade students Carter J, Wiecha J, Peterson KE, Gortmaker SL. Planet Health. Champaign, Illinois: Human Kinetics Press, 2001.

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

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

Planet Health Promotes... Active Learning Curriculum Frameworks Literacy Across the Curriculum

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

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)

Effects of Planet Health Obesity among females in intervention schools was reduced compared to controls (OR 0.48; P=0.03) Reductions in TV; both boys & girls Among girls, each hour of TV => reduced obesity (OR 0.86/hour; P=0.02) Increases in fruit and vegetable intake and less increment in total energy intake among girls (P=0.003 and P=0.05) 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. 1999;153:

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; P= Males: if the same school is dropped, intervention effect on obesity is OR 0.70; P=0.05

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 ) –White (OR 0.48; 95% CI ) –Hispanic (OR 0.38; 95% CI )

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, ).” 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 Mar;159(3):

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 Dec;16(10):

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 Nov;11(11):

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

The Important Forces: F ood producers and the "Fast Food" industry - if they’re successful, we all eat more A dvertisers for food and video/film industries - if they’re successful, we all buy more T elevision and video/film production and distribution industry - if they’re successful we all watch more

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

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

A Broad Vision of Our Work It’s 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.

Starting Young: Preventing Overweight in the Head Start Setting Funded by Harvard Pilgrim Health Care Foundation

Interdisciplinary curriculum for 4 th and 5 th grade Evaluation indicates improved dietary intake (total fat, sat fat, fruits/vegetables, vit C, & dietary fiber) and Reduced Television Viewing Eat Well and Keep Moving Eat Well & Keep Moving 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 1999;153: Cheung PLYH, Dart H, Gortmaker SL. Eat Well and Keep and Moving. Champaign, Illinois: Human Kinetics Press, 2001.

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

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

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

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.