Setting Up Camp: How Do We Improve Nutrition, Increase Physical Activity and Prevent and Control Obesity? William H. Dietz, MD, PhD Division of Nutrition, Physical Activity, and Obesity Centers for Disease Control and Prevention 2

DNPAO Functional Model Leadership, Management & Accountability Long-Range Planning Policy Analysis Admin./ Clerical Services Partnerships and External Relations Research Surveillance Training Translation & Dissemination Program Development and Technical Assistance

Division of Nutrition, Physical Activity, and Obesity Proposed October-2008 Office of the Director Bill Dietz Laurie Johnson Program Resource Management Associate Director for Translation and Dissemination Jude McDivitt Associate Director for Science Deb Galuska Associate Director for Policy , Partnerships, and Communication Vacant Nutrition Branch Larry Grummer-Strawn Paulette Murphy Research & Surveillance Team Surveillance Systems Team Guidelines Development & Recommendations Team International Unit (M/M) Physical Activity and Health Branch Mike Pratt (Acting) Lisa Kimbrough Research Team Surveillance Team Guidelines Development & Recommendations Team Obesity Prevention & Control Branch Bill Dietz (Acting) Tonya Ross) Research & Surveillance Team Guidelines Development and Recommendations Team Program Development & Evaluation Branch Rosanne Farris Becky Payne Program Advancement Team Program Development and Translation Team Evaluation Team

Office of Policy, Partnerships, and Communications Associate Director for Policy, Partnerships, And Communications Vacant, GS-685-15 Policy and Partnerships Team Casey Hannan, Team Leader (GS-685-14) Primary Team Functions: Coordination - legislative/policy issues Long-range planning Materials development: position papers, briefings, testimony, Q/A documents, etc. Inquiry response (policymakers/partners) FOIA Controlled correspondence Issues management Partnership development Communications Team Vacant, Team Leader (GS-1001-14) Primary Team Functions: Strategic communication plan Coordination - communication activities Audience research Message/materials development Web design/maintenance Inquiry response (media/public) Media relations Media training & TA Issues management

Overview of Efforts to Control Obesity Problem definition Strategy development - Targets - Strategies: policy and environmental change Implementation - Multi-sectoral - Evaluation Social movements 2

Overweight Prevalence by Race/Ethnicity for Boys Aged 6 - 11 Years Prevalence (%) Source: Ogden CL et al.JAMA. 2008;299:2401-5; MMWR 1997; 46:199-202

Overweight Prevalence by Race/Ethnicity for Girls Aged 6 - 11 Years Prevalence (%) Source: Ogden CL et al. JAMA. 2008;299:2401-5; ;MMWR. 1997:46:199-202.

Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years Ogden CL et al. JAMA 2008;299:2401

Broadcast advertising ban Annual Adult per Capita Cigarette Consumption and Major Smoking and Health Events – US 1900-1998 Thousands per year 1st World Conference on smoking and health Broadcast advertising ban 1st Surgeon General’s report 1st Great American smokeout End of WW II Nicotine medications Available over the counter Fairness Doctrine messages on TV and radio Master settlement agreement 1st smoking cancer concern Surgeon General’s report on environmental Tobacco smoke Nonsmoker’s rights movement begins Federal cigarette tax doubles Great Depression 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 1998 Year 2

Average Daily Energy Gap (kcal/day) Excess Weight Gained (Lb) Daily Energy Gap (kcal/day) All Teens 10 110 -165 Overweight Teens 58 678 -1,017 Behavioral implications of 150 kcal: Replacing 1 can of soda (12 oz) with water (140 kcal) Reducing TV watching by an hour (167 kcal/day)1 Walking 1.9 hours instead of sitting (for a 30-kg boy) Increasing PE from 1 to 3 times/week (240 kcal) Wang YC et al. Pediatrics 2006;118:e1721 Wiecha et al. 2006; Arch Pediatr Adolesc Med 160:436 10

Principal Targets Reduce energy intake Decrease high and increase low ED foods Increase fruit and vegetable intake Reduce sugar-sweetened beverages Decrease television time Breastfeeding Increase energy expenditure Increase daily physical activity 2

Policy Laws, regulations, formal and informal rules that are adopted on a collective basis to guide individual and collective behavior 2

Strategies to Increase Fruit and Vegetable Consumption Access – supermarkets School and community gardens Competitive pricing Packaging Stealth interventions (Garden Market) 2

Agreement between the Alliance for a Healthier Generation and the Soft Drink Companies Elementary schools H2O 8 oz juice without added sweeteners FF and LF regular and flavored milk Middle schools Same standards, 10 oz portions High schools No and low kcal drinks, light juices, sports drinks 50% must be H2O and no or low Kcal; 100Kcal/container 2

NYCDHMH, Amend Article 47, NYC Health Code; Applies to Group Day Care in NYC Television, video and other visual viewing Cannot be used for children <2 yo Limited 60 minutes per day of educational programs or programs that actively engage child movement for children 2+ yo 60’ physical activity required Eliminate sugar-sweetened beverages Provide 1% or no-fat milk

Principal Targets Reduce energy intake Decrease high and increase low ED foods Increase fruit and vegetable intake Reduce sugar-sweetened beverages Decrease television time Breastfeeding Increase energy expenditure Increase daily physical activity 2

Strategies to Increase Rates of Breastfeeding Maternity care practices Prenatal counseling Baby-friendly hospitals Workplace support for breastfeeding Peer support – peer counseling Professional support and education Public acceptance www.cdc.gov/breastfeeding 2

Role of Physical Activity in Weight Control Dose to prevent obesity unknown Dose to maintain weight after loss ~ 1 hr/d Relatively modest impact on weight loss Reduces obesity associated comorbidities 2

Effective Interventions to Promote Physical Activity Informational Community-wide education Point of decision prompts Behavioral and social School-based PE Non-family social support Individually adapted behavior change Environmental and policy Enhanced access with outreach Urban design and land use

The RE-AIM Framework R Reach E Effectiveness A Adoption I Implementation M Maintenance Glasgow RE et al. Ann Behav Med 2004;27:3-12 2

“To obtain more evidence-based practice we need more practice-based evidence” Green L, Ottoson JM. In Hiss et al, From Clinical Trials to Community: the Science of Translating Diabetes and Obesity Research, NIH, 2004.

Settings for the Prevention and Treatment of Obesity Medical Settings School Work Site Community

Chronic Care Model Environment Medical System Family/Patient Self-Management Family School Worksite Community Information Systems Decision Support Delivery System Design Self Management Support Dietz WH et al. Health Affairs 2007;26:430

Pediatric Initiatives Expert committee recommendations Maine and Massachusetts collaboratives NICHQ Network (NICHQ.org) NCQA – HEDIS measures AAP priority – Jeanne Lindros 2

Chronic Care Model Environment Medical System Family/Patient Self-Management Family School Worksite Community Information Systems Decision Support Delivery System Design Self Management Support Dietz WH et al. Health Affairs 2007;26:430

Settings for the Prevention and Treatment of Obesity Medical Settings School Work Site Community

Priority Physical Activity and Nutrition Actions for Schools Coordinated school health program and school health council Assessment and planning (School Health Index) Quality health education Staff wellness programs Additional opportunities for physical activity (e.g., recess, after school, walk to school) Quality PE Healthy school nutrition environment

% of Schools in Which Students Could Purchase Selected Food and Beverages From Vending Machines, School Store, Canteen, or Snack Bar, 2000 and 2006

Settings for the Prevention and Treatment of Obesity Medical Settings School Work Site Community

Model Worksite Interventions DNPAO Stairwells Sprint campus KP farmers’ markets and commissary policy NYC purchasing policy 2

Settings for the Prevention and Treatment of Obesity Medical Settings School Work Site Community

The Somerville, MA Intervention Increased low ED foods Discouraged high fat and sugar foods School wellness policy Enhanced school food service Healthy meeting and event policy Expanded pedestrian safety policies Walk to school campaign City employee fitness benefit Local physician training Economos et al. Obesity 2007;15:1325 2

Needs Identified at the CDC’s Community Meeting Development of a national strategic plan Clearinghouse for obesity prevention and control programs Evidence-based and promising interventions Training in HEAL for policymakers Standardized evaluation tools Flexible comprehensive funding 2

Largest Connected Subcomponent in Framingham Heart Study Christakis and Fowler. NEJM 2007;357:370

A National Convergence Around Healthy Eating, Active Living Steps to a Healthier US

Elements Common to Social Movements Shared and personalized perception of a threat Common frame Grass roots commitment Social network focused on collective action Local nodes with dense social ties, linked to other groups with weak bridging ties (rapid diffusion of innovation) Organizational structure 2

Paul Revere’s Ride by David Hackett Fischer