1. Shape Up Somerville Shape Up Somerville: A Community-Based Environmental Change Obesity Prevention Intervention Christina Economos, Ph.D. New Balance Chair in Childhood Nutrition Friedman School of Nutrition Science and Policy Tufts University, Boston MA R06/CCR121519-01 from the Centers for Disease Control and Prevention. Additional support was provided by Blue Cross Blue Shield of Massachusetts, United Way of Mass Bay, The Potato Board, Stonyfield Farm, and Dole Foods.

2. BACKGROUND Proactive strategies required to prevent childhood obesity Individual behaviors must be addressed in the context of societal and environmental influences Most prevention studies target school environments Summer weight change recently shown to outpace expected gains with growth and development Community-based interventions that have a theoretical framework and are mutli-level and participatory in nature are needed to catalyze social change

3. The Society-Behavior-Biology Nexus as depicted in multidimensional space Glass and McAtee Social Science & Medicine Volume 62, Issue 7, April 2006, Pages 1650-1671ocial Science & MedicineVolume 62, Issue 7

4. l Learn from other movements (tobacco, recycling, seat belts, breastfeeding) l Call for a Crisis l Build on a sound scientific base l Nurture spark plugs l Recognize the importance of economics l Develop coalitions and advocacy l Use government strategically l Employ mass communication l Create environmental and policy changes l Develop a clear plan How do you spark social change? Economos, C, Brownson, S, DeAngelis, M, Foerster, S, Tucker Foreman, C, Kumanyika, S, Pate R. What Lessons Have Been Learned From Other Attempts To Guide Social Change? Nutrition Reviews 2001; 59(3):40-56

5. A community-based, participatory, environmental approach to prevent childhood obesity A 3 year controlled trial to study 1st – 3rd grade culturally and ethnically diverse children and their parents from 3 cities outside Boston Goals: –To examine the effectiveness of the model on the prevention of undesirable weight gain in children –Transform a community and inform social change at the national level Shape Up Somerville: Eat Smart. Play Hard.

6. CBPR Community-based participatory research (CBPR) includes a collaborative partnership with the community in all phases of the research: –identifying the problem –designing, implementing and evaluating the intervention –building community capacity –identifying how data informs actions to improve health within the community Potential to influence cultural and social norms

7. Community Engagement Model Community Mapping: Understanding connections Participation Assessment: Identifying partners Information Gathering & Delivery Capacity Building: Making it happen Model Adapted from National Resources Canada Employ The Social Change Model of Leadership Development Hold community meetings Community council formation Perform environmental assessments Logo and brand development Conduct focus groups & key informant interviews Listen… Build Relationships & Establish Trust Identify the problem as a community priority Capitalize on social injustices Identify champions

8. Study Timeline Planning and monitoring year Oct 02-Sept 03 Year 1 Intervention Oct 03-Sept 04 Year 2 Intervention Oct 04-Sept 05 Baseline Pre School Year 1 Measurement Oct 03 Post School Year 1 Measurement May 04 Pre School Year 2 Measurement Sept 04 Post School Year 2 Measurement May 05 Summer

9. Baseline Overweight Prevalence At risk:  85 th to < 95 th percentile Overweight:  95 th percentile Reference: CDC 2000 Ogden JAMA 2006, Economos, 2003

10. INTERVENTION Designed to increase energy expenditure (EE) of up to 125 kcals per day beyond the increases in EE and energy intake that accompany growth Variety of increased opportunities for physical activity Availability of foods of lower energy density, emphasizing fruits, vegetables, whole grains, and low-fat dairy; foods high in fat and sugar were discouraged Multi-level approach: –Before, during, after school, home, community

11. (~25 kcals) Home: Parent, Child, Family Home: Parent, Child, Family Home: Parent, Child, Family School: Child, teachers, administration, staff School: Child, teachers, administration, staff School: Child, teachers, administration, staff Community: After school programs Community: Ethnic groups Local Government Health Care System Community: Restaurants Media

12. Skills Development

13. Experiential Learning

14. Demonstrations

15. A La Carte Options: Before Shape Up….

16. After…Improved A La Carte Options

17. A La Carte Snack Sales Data Sales fell from Sept. 2003 to Dec. 2003, making about $7,000 - $9,000/month less in revenues compared to 2002 data. Sales began to increasing in winter of 2004, showing increased student acceptance for new mix of products As of Oct. 2004 sales are now fairly even with sales prior to intervention Data is consistent with trends reported from other school systems. Revenue totals include Paid Lunches, Milk Purchases, and Teacher Sales in addition to A La Carte sales

18. HEAT Club: After School Program

19. Before school : Walking School Bus

20. Support from Community Champions A year of consultation and guidance for being a visible role model Mayor Joe Curtatone Aldermen School Committee Members

21. Growing food, knowing food School Gardens and Nutrition Education

22. Shape Up Somerville : Results Engaged 90 teachers in 100% of 1-3 grade classrooms (N=81) Participated in or conducted 100 community events and 4 parent forums Trained 50 medical professionals Recruited 21 restaurants Reached 811 families through 9 parent newsletters, and 353 community partners through 6 community newsletters Reached over 20,000 through a monthly media piece (11 months) Recruited all 14 after-school programs Developed community-wide policies to promote and sustain change

23. Demographic Characteristics at Baseline InterventionControl 1Control 2 N=342N=485N=207 Age (y) 7.90 ± 1.09 7.32 ± 0.93 7.82 ± 1.03 Grade (%) One 31.3%48.0%38.2% Two 32.2%24.7%27.1% Three 36.5%27.2%34.8% Ethnicity (%) White 50.3%37.5%51.7% Black 8.5%25.6%6.3% Hispanic 19.0%9.7%23.7% Asian 8.8%2.3%7.2% Other 13.5%24.9%11.1% Non-English Home Language (%) 33.6%14.8%34.3%

24. Results of Change in BMI z-score PRE-POST Intervention (N = 1178), Coefficients with p-values Adjusted for all variables shown above plus the 30 participating schools First Year Results

26. Limitations / Strengths Controlled, but not randomized Up-front investment both time and labor intensive Dissemination and replication will require community collaboration Measured and followed a subset of the eligible population Recruited and retained a large sample of ethnic and racially diverse, high-risk children from three communities One of the first community-based obesity prevention project to demonstrate prevention of weight gain

27. IMPLICATIONS Comprehensive strategies that involve changes in multiple environments reinforced with policies that ensure healthy living are a viable and necessary direction for the future

28. Nurture and follow the champions Some community members may need a little nudge to get them to initiate things on their own; others are already leading. Build initial relationships through key informant interviews The process of asking community members for their opinions and input informs, empowers, and lays the foundation for trust. School Administration buy-in is key If you want anything to happen on a school-wide level you need approval and support from the principals and superintendent. Global Lessons Learned: Build Support Networks

29. Keep the community informed of what you are doing. Build community support and recognition of the project by informing community leaders who may not be involved in your specific work. Engage people with family and community newsletters, letters to the editor, by publicizing events and by participating in discussions at town meetings and other committees. Global Lessons Learned: Communications

30. Create mechanisms to hold people accountable Environments that have enforced policies, monthly meetings, and/or consistent monitoring are easier to work with. When appropriate, ask programs and individuals to sign contracts, memorandums of commitment, or pledges. Global Lessons Learned: Accountability

31. Provide professional development opportunities for those involved in your intervention i.e. teachers, food service directors, after school program leaders Trainings allow for:  Reinforcement and transfer of knowledge  Relationship growth  Continued empowerment  Sense of personal investment  Program Sustainability Global Lessons Learned: Professional Development

32. Say yes when you can in the community Put your program agenda aside to build relationships and trust. Support other initiatives and issues in the community even if they have no direct link to your work. During your planning year – LISTEN Be realistic in your planning year: think about what you have heard, rather than what you want to achieve. There’s much to learn from others. Global Lessons Learned: Community Relations

33. Provide stipends when you can. Respect the time of professionals by offering compensation. It will open doors and encourage collaboration. Being present at events is key, not the materials you bring Go to as many community events as possible. Reach out to other providers and learn about other community issues. Reach out to Community Leaders You are surrounded by experts and sources of knowledge. Network with them. Global Lessons Learned: Community Relations

34. Bring key stakeholders to the table Having the right people helps your project move ahead. Constantly assess whether or not you have the key decision makers as part of your discussions. These players can change over time; be sure to know who does what in your community. Parent engagement is easiest through personal connection Ask your partners to invite parents that they know to your events. Global Lessons Learned: Don’t be Shy

35. Each community has different strengths and resources Social change is slow and dependent on the health and strength of relationships Focus on interventions that have: Designated leadership Designated meeting times for leadership Sustainability potential Global Lessons Learned: There is no MAGIC bullet

36. Replicating the intervention across the country through a RCT with 6 urban communities. RFA available at www.childreninbalance.orgwww.childreninbalance.org Adapting and implementing the intervention through a RCT in 8 communities in rural America (CA, MS, KY, SC) with Save the Children Distributing the HEAT Club after school curriculum through live and online trainings throughout the U.S. (>150 ASPs in 20 states) including an RCT Tipping the Scales for HPHCF Beyond Somerville

37. Tipping the Scales MA, ME, NH Key informant interviews – 75 to date Research and programmatic activities Wellness policies Legislation BMI data

38. Tipping the Scales Data analysis underway Preliminary observations –Awareness is high –Interest in and efforts to control further growth of the problem are widespread and cross many sectors within the three states –Appreciation for pressures schools face –Impressive number of activities underway Limited number include an evaluation component. Differences of opinion about the role of growth monitoring Physician’s efforts encouraging Exciting efforts to develop resources to increase physical activity

39. www.childreninbalance.org