Moving Guilford County toward a Healthy Weight€¦ · Scope of the Problem Eating behaviors In US, only 21-25% are consuming recommended 5+ servings of F&V/day In NC, only 23% of

UNC Center for Health Promotion and Disease Prevention

Alice Ammerman, DrPH, RD

May May Leung, MS, RD

Kelly Nordby, MPH, RD

Janice Sommers, MPH

Moving Guilford County toward Moving Guilford County toward a Healthy Weight a Healthy Weight

Finding the Will and the WayFinding the Will and the Way

White Paper PresentationAugust 31, 2009

Making Good Health HappenMaking Good Health HappenMoses Cone-Wesley Long Community Health Foundation

Topics Covered

Scope and complexity of the Problem

White Paper Process

Contributing Factors

Current Obesity Prevention Initiatives

Guilford County Assets and Needs

Intervention Strategies

RecommendationsGeneral

Community

Schools/Child Care

Worksite

Healthcare

Evaluating Success

Systems Dynamic Modeling – Key Feedback Loops: Obesity

Scope of the Problem

Obesity rates have doubled in adults and tripled in children over the last 30 years (Ogden et

al., 2006)

US prevalence (overweight or obese):66% of adults are overweight or obese (Schiller et al., 2005)

25% of children ages 2-5 (Ogden et al., 2006)

33% of 6-19 year olds (Ogden et al., 2006)

NC prevalence (overweight or obese):66% of adults (NC BRFSS)

31% of children (5th highest in the US) (NC BRFSS)


Guilford County Prevalence (overweight or obese)

68% of adults – slightly higher than US and high end of range for NC (NC counties range 46.5% to 74.9%)

22.5% of middle/high school students (2008 YRBS; self report data from students describing themselves as ‘slightly’ or ‘very’ overweight)


Disparities among Obese Individuals

In North Carolina, obesity is greater among:African-Americans/Hispanics vs. Whites

Adults vs. youth

Poor vs. affluent


Percentage of NC Overweight or Obese Adults by Race (2008)

36 3441

38 36

27 4128

2230

0

20

40

60

80

100

White African American

Hispanic Other Minorities

AllAdults

Overweight ObeseSource: North Carolina Behavioral Risk Factor Surveillance System Survey, N.C. State Center for Health Statistics, N.C. Department of Health and Human Services, (2008).

75%63% 69%60%

66%


Percentageof NC Children and Youth who are Obese by Race and Age Group (2007)

01020304050

Perc

enta

ge

2-4 15.8 13.2 16.5 14.9 15.35-11 25.3 22.4 20.6 24.3 29.3 24.912-18 29.3 31.8 32.8 26.5 31.1 29.9

White African American

NativeAmerican Asian Hispanic Total

Source: North Carolina-Nutrition and Physical Activity Surveillance System (NC-NPASS)includes data on children seen in North Carolina

Public Health Sponsored WIC and Child Health Clinics and some School Based Health Centers. (2007)

20.3

Age


86% of Americans will be overweight/obese by 2030 unless habits change (Wang et al., 2008)

Obesity is second to cigarette smoking as major preventable cause of mortality

Obese workers have up to 21% higher health care costs compared to those with a healthy weight (DHHS, 2003)


National medical costs associated with obesity (Finkelstein et al., 2005, 2009)

1995 - $99 billion

2005 - $139 billion

2009 - $147 billion

NC costs associated with obesity (medical costs,

lost productivity, and workers compensation) (Chenoweth and Associates, 2005)

$24.1 billion

$16 million for childhood obesity alone


In 2007, more than half of leading causes of death in Guilford County were due to chronic diseases related to or exacerbated by obesity

Leading Causes of Death in Guilford County, 2007

Heart Disease 22.5%

Cancer 22.4%

Stroke 5.9%Unintentional Injuries 5.6%

Chronic Lower Respiratory Disease 5.2%

Others 38.3%Source: State of Guilford County’s Health Report, 2008


Eating behaviors

In US, only 21-25% are consuming recommended 5+ servings of F&V/day

In NC, only 23% of adults and ~15% of youth are consuming 5+ F&V/day (NC BRFSS, 2006; Health Profile of North Carolinians, 2007)

37% of NC youth drink one soda/day (YRBSS, 2007)

Physical Activity (NC BRFSS, 2006; Health Profile of North Carolinians, 2007)

In US, 40% of adults and 23% of youth get no leisure-time physical activity at all

In NC, 24.6% of adults get no physical activity, and only half of MS/HS students get recommended 60 minutes/day

White Paper Process

Epidemiologic data sources examinedObesity rates and determinants

Dietary/PA behaviors at national, state, local levels

15 Key Informant Interviews conducted with leaders in obesity prevention in Guilford County

Evidence previously compiled by Center for Training and Research Translation (Center TRT)


Causative/protective factors related to weight gain

Derived from systematic reviews of the evidence

Purpose:Identify areas to focus efforts for targeting interventions


NutritionIncreasing breastfeeding decreases risk of obesity. (WHO, 2003; Arenz, 2004)

A diet consisting of high energy-dense foods and refined grains is related to increased obesity (NC

BRFSS, 2007) and replacing these foods with F&V decreases risk of obesity (WHO, 2003; Arenz, 2004)

High intake of dietary fiber (e.g., whole grains, fruits, vegetable, legumes) decreases risk of obesity (Woodward et al., 2006)


Physical Activity

Regular physical activity decreases risk of obesity. (Fogelholm et al., 2000, Wareham et al., 2005; Strong et al., 2005)

A sedentary lifestyle is related to increased body fatness (Woodward-Lopez et al., 2006; Must et al., 2005)


Screen time and Other Factors

Screen time (TV viewing/Video games) is related to increased body fatness in children (ADA Evidence Library, 2009)

Food insecurity is linked to increased risk of obesity (Woodward-Lopez et al., 2006;Drewnowski, 2007)

Parenting influences may be a contributing factor in childhood obesity (Davis et al., 2007)

Current Obesity Prevention Initiatives – Statewide Assets

Healthy Carolinians –Fosters collaborations seeking health solutions

Provides training to local health departments for completion of community health assessment every 4 years

Helps communities identify how to target and focus efforts re: obesity prevention


North Carolina Action for Healthy KidsStatewide initiative dedicated to improving health and educational performance of children through improved nutrition and PA in schools

Focus - to implement Local Wellness Policies (LWP) in NC schools by using tools provided by

Successful Students Eat Smart Move More

Tools provided by this initiative can be used to assist school leaders with LWP implementation


Eat Smart Move More (ESMM)Initiative that promotes opportunities for healthy eating and physical activity in communities, schools, and worksites.

Established 5-year plan offering goals and measurable objectives for organizations working in obesity prevention

Can help identify, focus, and fund efforts on areas of obesity prevention

Community Assets:100+ miles of greenway trails in Guilford County (including a future 4.3 mile greenway in downtown Greensboro;

170 park facilities, including 40 neighborhood parks;

YMCAs and recreation centers;

Bicycling in Greensboro (BIG) program cycling educational sessions for socio and economically disadvantaged adults;


Community Assets (cont):YMCA Get Healthy Guilford Coalition - 65 agencies committed to obesity prevention efforts;

Guilford County Cooperative Extension sponsors farmers markets and community gardens;

Keely Park Community Gardenfunded project for culturally diverse communities

provides horticultural therapy for disabled persons;


Community Assets (cont): Kids in the Kitchen and Chef and Child programs- Guilford Cooperative extension sponsors cooking classes for children;

Nutrition education classes - Moses Cone Wesley Long Health System sponsored nutrition education programs open to members of the community, intended for those with diabetes;

Trans-fat free restaurants across Guilford County - voluntary effort led by the Guilford County Department of Public Health;



Community Needs:Marketing campaign to raise awareness of existing programs and resources targeting obesity prevention efforts

Evaluation plan to assess effectiveness of currently funded community initiatives

Increased access to healthy and affordable foods in low-income neighborhoods (ESMM Nutrition and PA Data Collection Project – GIS Mapping Project)

Increased access to safe places to engage in PA in low –income neighborhoods (ESMM Nutrition and PA Data Collection Project – GIS Mapping Project)

School/Daycare Assets:Team Nutrition - USDA Food and Nutrition Service funded effort that supports the Child Nutrition Programs

training

technical assistance for foodservice

nutrition education for children and their caregivers,


School/Daycare Assets cont:Smart-Start administered program- to reduce childhood obesity by implementing Nutrition and Physical Activity Self-assessment for Childcare (NAP SACC) program

Focus on policy and environmental change


School/Daycare Needs:Required daily 30 minutes of PA not implemented uniformly across the district

Vending machines contents not being monitored

Long lines for school lunch – motivating kids to get quicker, potentially less healthy options

Increased funding to offer more F&V


Worksite Assets:Health System Employee Wellness Program called Wellness Is Now (WIN) – incentive program for healthy lifestyle changes.

Reaches 70% of 7500 MCWL employees

My Health IQ – program that involves health counseling, online risk assessment, and biometric testing.

Participation allows employees to receive $500 discount off annual health care premiums



Worksite Needs:Flexibility for clinical employees to participate in worksite wellness initiatives and have more time to eat healthier meals while working

Increased availability of less expensive, healthy food options in the cafeteria


Healthcare Assets:Take Charge Weight Initiative – obesity treatment program offered by Guilford Child Health

Recommended for all patients with a BMI > 85th

percentile

Program provides: Health educationYMCA and sports scholarshipsIncentives for behavior changeSocial support for participating families


Healthcare Assets:Congregational Nurse Program

pairs nurses and faith communities

free health and nutrition education related to chronic disease screening and prevention


Healthcare Needs:Lack of funding for additional dietitians to conduct nutrition education with patients –especially a concern for low-income patients

Evaluation needed to assess outcome measures for clinical programs

Intervention Strategies

Target major behavioral factors that contribute to obesity:

Breastfeeding

Healthy Eating

Physical Activity

Identify the best available options for taking action to prevent and control obesity

Intervention Strategy Success Stories

Healthy EatingRhode Island thrive program

Helped school districts implement a new law, requiring all district strategic plans to include ways to decrease obesity and improve the health and wellness of students and employees. Established district-level health and wellness subcommittees to develop policies to meet the requirements of the federal Child Nutrition and Women, Infants, and Children Reauthorization Act of 2004.


Rhode Island thrive program Successes“Farm to Schools” program - partnership with a local orchard owner, a community farmer, and parent volunteersPolicy change in a middle school, requiring water and/or drinks containing at least 50% fruit juice to be sold in school vending machines, and eventually only healthy beverages and snacks in schools.


Physical ActivityKaBOOM!

National non-profit that empowers communities to build playgrounds

Extensive community involvement at all stages of planning, development, and building of playspace.

Through grants, training, online tools and publications, KaBOOM! has

Facilitated the building of more than 1,500 playgroundsInspired the building of more than 2,000 playgrounds

Healthy Eating and Physical Activity Nutrition and Physical Activity Self-Assessment in Childcare (NAP SACC)

Practice-based intervention that targets children ages 2-5 designed to enhance policies, practices, and environments in child care centers by improving the:

nutritional quality of food served,amount and quality of physical activity,staff-child interactions, andfacility nutrition and physical activity policies and practices and related environmental characteristics.


General Recommendations

Require and fund evaluation measures (for appropriate outcomes one might expect to change) to assess impact of funded projects

Evaluate existing projects and use data to inform the future of those programs (continue, modify, enhance, discontinue)

Target funding to the behavior(s) , geographic area(s), and populations that are of highest priority to the Community/Foundation


Partner with other foundations and organizations to more effectively influence practice, environmental and policy change

Focus efforts on prevention strategies that reach a large portion of the target population

Work at multiple levels (individual, family, organization, community, policy) to address targeted lifestyle behaviors that contribute to obesity


Involve priority populations in decision making, planning and implementation

Build the capacity of your community to implement and sustain interventions that support healthy eating and active living.

For each setting, consider funding evidence-based programs identified by the Center TRT, Cancer Planet, or those outlined in Section V: Success Stories of White Paper.

Include careful consideration of community partner input, the context, and required resources.

Recommendations: Community

Implement social marketing campaigns to promote awareness of current activity opportunities within Guilford County (greenway trails, public parks, community recreation centers)

Support efforts that promote safe neighborhoods, communities and buildings, which promote physical activity as part of a daily lifestyle.

Focus efforts on increasing accessibility and availability of fresh, local and healthy foods in all communities and neighborhoods.

ALICE WATERS’ EDIBLE SCHOOLYARD TAKES ROOT IN NCGreensboro Children’s Museum - First Museum with Edible Schoolyard in U.S.

Recommendations: Schools/Childcare

Increase awareness and promote implementation of school wellness policies

Use resources provided by the North Carolina Action for Healthy Kids

Fund pilot projects that create healthy active school/daycare environments - possible models

Work toward a policy in Guilford County to have Physical Education (PE) specialists teach PE in all schools.

Recommendations: Worksite

Support efforts of worksites and employers that offer and promote opportunities for physical activity.

Support efforts of worksites and employers that offer and promote access to healthy foods/beverages.

Recommendations: Healthcare

Work toward physician adoption of standards of practice that include routine screening of BMI (Body Mass Index), counseling and behavioral interventions to improve dietary and PA

Implement policies and practices in hospitals and outpatient medical facilities to support successful initiation and continuation of breastfeeding

The KESMM Tools Provider Toolkit

Self Monitoring Log

Color Coded BMI

Starting the Conversation (STC)

What Are The KESMM Tools? (cont.)

CM / EFNEP Paraprofessional Toolkits

FESMM Toolkit Shopping List Self Monitoring Log

Study Resources and Materials Kit

8-10 Nutrition and Physical Activity Lessons

Evaluating Success

Monitor progress of funded efforts toward meeting Foundation goals.

BMI should NOT be the primary indicator of success - unlikely to occur as a result of any one intervention during usual funding cycle.

Essential that intermediate markers of progress form the basis of evaluation efforts.

Evaluating Success

Establish a set of community measures or indicators of success to track progress

Use CDC set of 24 “common community measures” to monitor progress towards meeting policy and environmental change goals in communities.

Strategies to Promote the Availability of Affordable Healthy Food and Beverages

1. Increase Availability of Healthier Food and Beverage Choices in Public Service Venues2. Improve Availability of Affordable Healthier Food and Beverage Choices in Public Service Venues3. Improve Geographic Availability of Supermarkets in Underserved Areas4. Provide Incentives to Food Retailers to Locate in and/or Offer Healthier Food and Beverage Choices in Underserved Areas5. Improve Availability of Mechanisms for Purchasing Foods from Farms6. Provide Incentives for the Production, Distribution, and Procurement of Foods from Local Farms7. Restrict Availability of Less Healthy Foods and Beverages in Public Service Venues8. Institute Smaller Portion Size Options in Public Service Venues9. Limit Advertisements of Less Healthy Foods and Beverages10. Discourage Consumption of Sugar-Sweetened Beverages11. Increase Support for Breastfeeding

Strategies to Encourage Physical Activity or Limit Sedentary Activity Among Children and Youth

12. Require Physical Education in Schools13. Increase the Amount of Physical Activity in PE Programs in Schools14. Increase Opportunities for Extracurricular Physical Activity15. Reduce Screen Time in Public Service Venues

Strategies to Create Safe Communities That Support Physical Activity16. Improve Access to Outdoor Recreational Facilities17. Enhance Infrastructure Supporting Bicycling 18. Enhance Infrastructure Supporting Walking 19. Support Locating Schools within Easy Walking Distance of Residential Areas20. Improve Access to Public Transportation21. Zone for Mixed-Use Development22. Enhance Personal Safety in Areas Where Persons Are or Could Be Physically Active23. Enhance Traffic Safety in Areas Where Persons Are or Could Be Physically Active

Strategy to Encourage Communities to Organize for Change24. Participate in Community Coalitions or Partnerships to Address Obesity

Evaluating Success

Develop a logic model to guide funding and evaluation

Monitors success along a continuum and includes: Resources

Activities

Outputs (tangible results) of the activities –can be counted

Outcomes:Short term (1-3 year)/Medium term (3 – 5 year) – e.g., implementation of a policy or outcomes based on evaluation metrics selected for settingLong term (5 – 10 year) outcomes – e.g., institutionalization of systems changes, spread of interventions to other groups, improvement of targeted behaviors

Evaluating Success

Partner with an academic institution with expertise in nutrition, physical activity and program evaluation

Develop an overall evaluation framework to track progress in meeting community goals, and assist grantees with evaluation design, data collection systems and reporting mechanisms.

Don’t be discouraged…

The problem is so “big” almost anything you do is likely to help!

Build on strengths and existing programs –there are many.

Circle the wagons – coordinate efforts focusing on obesity prevention and control so that they reinforce vs. compete.

Evaluate, learn, and adjust

Moving Guilford County toward a Healthy Weight€¦ · Scope of the Problem Eating behaviors In US, only 21-25% are consuming recommended 5+ servings of F&V/day In NC, only 23% of

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