Next steps in obesity Prevention:  Altering early life systems to support  healthy Parents, infants, and toddlers
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Next steps in obesity Prevention: Altering early life systems to support healthy Parents, infants, and toddlers



There is an urgent need for effective, sustainable child obesity prevention strategies. Progress toward this goal requires strengthening current approaches to add a component that addresses pregnancy ...

There is an urgent need for effective, sustainable child obesity prevention strategies. Progress toward this goal requires strengthening current approaches to add a component that addresses pregnancy onward. Altering early-life systems that promote intergenerational transmission of obesity holds promise for interrupting the continuing cycle of the obesity epidemic. A 2011 Institute of
Medicine (IOM) report emphasizes the need for interventions early in life to prevent obesity. A 2010 IOM report called for addressing gaps in existing obesity research evidence by using a systems perspective, simultaneously addressing interacting obesity promoting factors in multiple sectors and at multiple societal levels. A review of evidence from basic science, prevention, and systems
research supports an approach that (1) begins at the earliest stages of development, and (2) uses a systems framework to simultaneously implement health behavior and environmental changes in communities.



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Next steps in obesity Prevention:  Altering early life systems to support  healthy Parents, infants, and toddlers Next steps in obesity Prevention: Altering early life systems to support healthy Parents, infants, and toddlers Document Transcript

  • childhood Obesity June 2012 | Volume 8, Number 3 review © Mary Ann Liebert, Inc. DOI: 10.1089/chi.2012.0004 Next Steps in Obesity Prevention: Altering Early Life Systems To Support Healthy Parents, Infants, and Toddlers Philip R. Nader, M.D.,1 Terry T.-K. Huang, Ph.D., M.P.H.,2 Sheila Gahagan, M.D., M.P.H.,1 Shiriki Kumanyika, Ph.D., M.P.H.,3 Ross A. Hammond, Ph.D.,4 and Katherine Kaufer Christoffel, M.D., M.P.H.5 Abstract There is an urgent need for effective, sustainable child obesity prevention strategies. Progress toward this goal requires strength- ening current approaches to add a component that addresses pregnancy onward. Altering early-life systems that promote intergen- erational transmission of obesity holds promise for interrupting the continuing cycle of the obesity epidemic. A 2011 Institute of Medicine (IOM) report emphasizes the need for interventions early in life to prevent obesity.  A 2010 IOM report called for address- ing gaps in existing obesity research evidence by using a systems perspective, simultaneously addressing interacting obesity pro- moting factors in multiple sectors and at multiple societal levels. A review of evidence from basic science, prevention, and systems research supports an approach that (1) begins at the earliest stages of development, and (2) uses a systems framework to simultane- ously implement health behavior and environmental changes in communities. high-risk mothers who have high-risk infants, who in turn Introduction O become high-risk children and adolescents, and the cycle ver the past several generations, societal changes continues. This information suggests that interrupting the have led to the obesity epidemic, with attendant effects of “obesogenic systems”9 early in life holds prom- health and economic consequences demanding ise. new scientific approaches, policy, and actions.1 Obesity is In the United States, obesity now affects over 10% of a complex problem involving contributing factors at mul- preschool children; an additional 10% are overweight.10 tiple levels of social organization, including the family Among low-income children, rates are even higher, with (and its lifestyle habits), community structures and ser- 14% being obese. 11–13 Obese preschoolers are likely to vices (that provide or impede access to healthy food and be obese later in childhood14 and suffer obesity-related safe activity), and broad societal forces (and related poli- co-morbidities. Adverse effects of obesity appear as early cies, public understanding, and funding).2 There is grow- as 3 years old, with obese children exhibiting inflamma- ing evidence that risk for childhood obesity is already tory biomarkers linked to risk for later heart disease. 15 present during gestation and even before pregnancy via The potential for childhood obesity to be precociously maternal weight and epigenetic influences from the prior “locked in,”16 along with the persistence of obesity from generation.3–8 Figure 1 provides a schematic view of the early childhood to adolescence and adulthood,3,17 support developmental and intergenerational effects of obesity, the need for interventions to begin early in the life cycle. identifying six elements in an ongoing cycle of obesity The resulting burden—poor health, health disparities, risk and transmission. High-risk adolescent girls become and related costs—is likely to continue to accumulate for 1 Department of Pediatrics, University of California, San Diego, La Jolla, CA. 2 Department of Health Promotion and Social and Behavioral Health, University of Nebraska Medical Center, Omaha, NE. 3 Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 4 Center on Social Dynamics and Policy,The Brookings Institution,Washington, DC. 5 Departments of Pediatrics and Preventive Medicine, Northwestern University, Chicago, IL. 195CHI 8.3 Jun 12 v1.indd 195 5/9/12 11:56 AM
  • 196 nader et al. Reproductive age Adolescence 5 6 Intergenerational impact Carry over effects across 4 developmental stages Pregnancy of risks Childhood 1 3 Infancy 2 Toddlerhood Figure 1. Developmental and intergenerational effects of obesity. Significant interstage events include: 1, Intrauterine programming; 2, breastfeeding, early food exposure, attachment stage; 3, early childhood growth, child care, habit formation; 4, brain maturation, self-management, puberty, health behavior change, increased salience of peer effects and school effects; 5, independence, increasing life stress; 6, preconceptual health, parental health status, prenatal care. decades 18 unless we implement sustainable prevention Cochrane review19 suggests that obesity prevention inter- measures earlier in the life cycle. ventions may produce the largest magnitude of effect early in life. Despite this optimistic evidence, how- ever, the epidemic of childhood obesity persists19 and the Methods impact of fetal overnutrition as a risk for continuing adult obesity may continue to reinforce this vicious cycle at the The co-authors, a multidisciplinary group of senior population level in the United States.20,21 Two Institute investigators, conducted a series of discussions on our of Medicine (IOM) reports emphasize both the need for understanding of the strengths and weaknesses of cur- interventions early in life22 and the use of a “systems per- rent approaches to the prevention of childhood obesity. A spective”23 to fill in gaps in obesity research evidence that targeted literature review was conducted using PubMed, can more effectively guide policy. There is no currently beginning with the search terms "obesity," "prevention," available framework or strategy that has been proposed and "intervention." The search was narrowed to include to translate these IOM recommendations into action. On publications related to pregnant women, infants, children, the basis of the results of our review of evidence from and adolescents. We began with review articles and used basic science, prevention, and systems research, presented the bibliographies to identify primary studies. We then below, and applied to pregnancy and before and infancy identified studies that cited those studies to insure the through preschool, this article presents for discussion most current literature review. This review process was a strategy to interrupt the continued progression of the extensive beginning with 1438 references. We used the childhood obesity epidemic. The twin premises of the U.S. Preventive Services Task Force system to rank evi- approach we propose are: (1) Intervention is necessary dence and to rank order studies to include in our review. before, during, and after pregnancy, and for very young Results of the review were used to support the need for children, and (2) systems approaches are needed for sus- and refine a broader early life cycle approach to the pre- tainable prevention of childhood obesity and its conse- vention of childhood obesity. quences. Results Pregnancy and Before Parental overweight conveys a major risk for over- Most efforts to combat childhood obesity have focused weight in children, for which both parents’ long-term on school-aged children and adolescents. The latest overweight or obesity is the strongest single predictor.24CHI 8.3 Jun 12 v1.indd 196 5/9/12 11:56 AM
  • childhood Obesity June 2012 197 Maternal obesity before and during pregnancy disrupts and adequate intervention and follow-up time increased glucose homeostasis, insulin sensitivity, amino acid syn- the likelihood of effectiveness.47 thesis, and fat metabolism, increasing risk for subsequent In summary, current evidence supports increased obesity and disease in the offspring.25,26 Furthermore, ges- emphasis in obesity prevention efforts on promoting: tational weight gain is an independent risk factor for obe- Optimal preconceptual weight, avoiding excessive ges- sity in the child.27 Both high and low birth weights (linked tational weight gain, returning toward a healthy postpar- to maternal obesity) are also associated with higher tum weight, breastfeeding promotion, monitoring infant maternal and infant complications and the development of growth for rapid weight gain, promotion of healthy wean- childhood obesity. Therefore, interventions in pregnancy ing foods, limiting screen time, and child care practices48 and early life offer promise for decreasing obesity preva- that promote healthy nutrition and physical activity in lence, as both are sensitive periods in which rapid weight young children. gain creates risk for obesity.28 Preventing preconception obesity and excessive pregnancy weight gain and avoid- ing postpartum weight retention are important strategies A Systems Approach for reducing obesity prevalence in adult women.29 In Proj- A systems approach is one that explicitly focuses on the ect Viva, walking and vigorous physical activity in mid- interconnections between different aspects of the environ- pregnancy were protective against excessive gestational ment and between individuals and the environment. This weight gain.30 Individual counseling, self-monitoring of is what distinguishes a systems approach from a tradition- diet and activity, and education paired with motivational al multilevel or multicomponent model. Multicomponent interviewing are effective strategies in limiting excessive interventions are not the same as systems interventions. weight gain. In addition, postpartum weight loss reduces Adding systems approaches to whole community—mul- the likelihood of high birth weight and risk for later obe- tilevel, multicomponent—interventions allows investiga- sity in the next child.31 tors from the onset to determine the interactions among the systems and sectors that will be required to result Infancy to Preschool in intervention sustainability (persistence of changes Rapid weight gain during infancy significantly increas- made and ongoing adoption of new ones), scalability es the risk of later obesity. 32–35 Therefore, monitoring (diffusion across settings), and reach (across population infant weight gain and attention to nutrition during the subgroups).49–52 This is a crucial addition that may well first 12 months is crucial. Breastfeeding is associated with assure adequate strength of the interventions and lead to a a small but significant reduction in risk for obesity, and wider population change that will impact the course of the breastfeeding promotion interventions can be successful.36 epidemic. The concept of multilevel influences on human Recent analyses from the Feeding Infants and Toddlers behavior is well established in public health research Study indicate that the diets of young children remain and practice as the “ecological model.”53 Socioecological less than optimal, with too many “empty calorie” foods models advocate for combining individual and environ- consumed by children, even in the first year.37,38 Pairing mental approaches, but do not address how the different breastfeeding with healthful weaning foods is likely to levels influence each other and whether that makes a dif- promote healthy weight trajectories.39–43 ference in the overall outcomes. Socioecological models Attention to nutrition, physical activity, and screen time also do not inform what is the optimal mix and sequence are important strategies in early childhood, and parents of intervention strategies to bring about sustained popula- are important influences on all three. A recent review of tion-wide impact. This is important given new evidence effectiveness of interventions aimed at reducing screen that adult weight gain and loss do not occur in a linear time found that while overall there was no evidence of trajectory,54 suggesting that different combinations and/ impact on BMI, interventions among the preschool age or sequences of interventions of varying modalities may group held promise.44 A primary care–based intervention be needed throughout the developmental pathway to bring directed to 2- to 6-year-old overweight and obese chil- about sustained population impact across the age span dren did not impact BMI, but the authors suggested that influenced by early life-cycle systems. broader approaches could be more effective than primary Evolving systems methods49 offer tools to anticipate healthcare interventions alone. 45 Nutrition and physical and leverage complex interactions, feedbacks, and conse- activity practices in nonparental child care sites impact quences in planning interventions. For example, aligning 61% of U.S. children less than 6 years old. 46 The IOM priorities in disparate sectors (e.g., early child care sys- report on early childhood obesity prevention22 calls atten- tems, public schools, health agencies, and primary care tion to community environmental influences on childhood providers) will lead to new interactions between sectors. obesity. Individual-, family-, and center-based early child- These interinstitutional alignments can be defined by sys- hood obesity interventions have been effective, using a tems interactions and can estimate the synergistic effects combination of nutrition education, guided physical activ- of coordinating separate sector interventions. Systems ity, limitation of television viewing, and/or remuneration methods can also identify key mechanisms at work that for participation. Attention to environmental determinants affect the evaluation of interventions. Complex interac-CHI 8.3 Jun 12 v1.indd 197 5/9/12 11:56 AM
  • 198 nader et al. tion effects, nonlinearities, and dynamic feedback can be projects Shape Up Somerville62 (a city-wide campaign difficult to capture in traditional statistical approaches to increase daily physical activity and healthy eating in and randomized controlled trial interventions and designs. Somerville, MA) and “Together Let’s Prevent Childhood Systems modeling can provide a valuable complement to Obesity” 63 (EPODE, in numerous cities and towns in conventional research methods.50,55 Systems tools can also Europe). These interventions have resulted in less weight help us anticipate unintended consequences when other- gain in older children and adolescents. Whole community wise well-intended interventions are implemented.49,50 systems approaches aimed much earlier in the life cycle Although there is broad agreement that obesity is deter- remain to be tested. mined by factors at multiple levels of social organization and across sectors—from the food industry to transporta- tion policy—public health and healthcare systems have A Systems Framework To Prevent been somewhat slow to embrace a systems approach to Obesity by Targeting Early Life prevention. However, whole community interventions to prevent obesity in the United States and elsewhere are To provide a framework to guide the implementation of documented and continue to be evaluated.56–61 Many of a systems approach targeting early life, Figure 2 illustrates these interventions focus on changing social norms via how policies and practices at the local, state, and national community health promotion (nutrition education and level directly and indirectly affect community-level physi- media), school and community mobilization, leadership cal and social environments, the economic environment, by political officials, business participation, and attempts healthcare systems, and family and individual health to remove individual-level barriers to healthy eating and behaviors. These systems influence health behaviors and physical activity. Examples include the multicomponent environments that impact both adults and children simul- Figure 2. A community systems framework of early intervention of childhood obesity with feedbacks between individuals and the environment. Systems pathways: 1. Policies related to urban planning, housing, transportation, parks and recreation, food availability, access, financing and marketing, and edu- cation. 2. Policies on media and information, housing segregation, industry practices, labor, individual incentives (tax, insurance). 3. Policies on healthcare infrastructure, financing, delivery mode. 4. Interplay between social and physical environment. 5. Social and physical environments enable and/or constrain family and individual behavior. Individuals can also shape their environment. 6. Preventive and treatment services to families and individuals. 7. Healthcare providers’ behaviors and practices, policies, and as advocates for social and environmental changes to promote healthy lifestyles. 8. Individual empowerment and community mobilization to effect policy change.CHI 8.3 Jun 12 v1.indd 198 5/9/12 11:56 AM
  • childhood Obesity June 2012 199 taneously, principally in the family setting, but also within enced by local, state, and national policies and can also community institutions, such as child care and schools be changed through advocacy by individuals, families, for children, work site and neighborhoods for adults, and and institutions. Advocacy and policy go hand in hand. healthcare systems for both children and adults.64 Systems Examples of physical environments include lack of access interaction pathways (1–8, see Fig. 2) are identified, giv- to fresh vegetables and fruits in certain neighborhoods ing a template for designing interventions that specifically (“food deserts”), or lack of safe places to walk, exercise, enhance pathways that promote healthy behaviors, and dis- or ride bikes. Healthcare and community systems provide rupt pathways that perpetuate obesity, requiring program- obesity prevention and treatment services to individuals ming impacting both adults and children. and families and are also influenced by local, state, and System pathways impact behaviors that ultimately national policies. Direct advocacy by primary care health determine weight status. As illustrated in Figure 2, for practitioners and others who work within community mothers and young children, these eating and activity health systems is an important pathway to change physi- behaviors are nested within family and cultural beliefs, cal and social environments in communities. customs and habit, and adult behaviors and role model- Complex systems-oriented inteventions 65 are geared ing related to child feeding and physical activity. Parental toward generating solutions to real-world situations that choices for their own and their children’s behaviors are continually change. Such system issues become critical influenced by the relative costs involved for parents. to intervention design, and effectiveness, with focused Interventions that deal with relative cost issues to families attention to contextual issues unique to each community. may yield faster change than those related to family cul- Because obesity prevalence among children and adults var- tural norms and attitudes. Supports in physical environ- ies by geographic area, race/ethnicity, and socioeconomic ments (e.g., settings where children and young families status,66,67 “place-based” community and family interven- spend time, neighborhood characteristics) and social tions aiming to prevent excessive maternal weight gain environments (e.g., social relationships, social norms, and during pregnancy and caloric balance in young mothers cultural influences) are shown as key factors that enable and children are proposed. Little is known about cost-effec- or constrain family and individual behavior. Because the tiveness68 of obesity prevention strategies and the potential physical environment can shape the social and cultural of systems approaches69 at this early stage. environment over time, and the social and cultural envi- Evidenced-based sustainable behavior change interven- ronment can perpetuate the status quo in the physical tions70,71 that parallel policy and environmental change environment, both need to be addressed simultaneously efforts are key components, with a common set of health to disrupt the lockstep cycle that prevents progress and behavior goals for the three target developmental stag- change. Physical and social environments are influ- es—pregnancy, infancy, and toddler. The goals (shown in Table 1) are categorical rather than specific in recog- nition that prevailing guidelines will change over time. Table 1. Early Life Systems: Table 2 gives examples of what this approach would Key Behavior Intervention Targets look like to influence change through the pathways in Pregnancy Figure 2. For example, access to fresh foods could be • Engage in early prenatal, post-natal, and inter-conceptual care enhanced via pathways 1 and 2 through policies promot- • Achieve healthy gestational weight gain ing use of food stamps for fresh fruits and vegetables • Post-partum return towards a healthy weight at farmer’s markets. The primary healthcare sector can implement the latest patient care protocols supporting • Prepare to breast feed healthy weight in mothers and young children and make Infancy available family-based health promotion behavior change • Initiate and maintain breast feeding classes (pathway 6). The health sector can also advocate • Appropriate introduction of other beverages and foods (pathway 7) with government, schools, early child care • Support for healthy sleep patterns groups, and birthing hospitals to adopt policies that cre- • Support for appropriate soothing, not always using food ate environments that support families to carry out the behavioral goals listed in Table 1. Table 3 summarizes • Support for motor development examples of policy, professional action, and public edu- • Avoid excessive weight gain in infancy cation targets for early life systems change organized by • Avoid screen time developmental stage. Toddler Years • Active play at least one hour per day, limitation of screen time •  onsumption of healthy foods, snacks, and un-sweetened C Discussion beverages in appropriate portion sizes Beginning obesity prevention in pregnancy has been • Healthy nutrition and activity standards in childcare settings suggested before,26 but not with the supporting rationale • Limit screen time and systems strategies proposed in this paper. Whole community interventions addressing both policy andCHI 8.3 Jun 12 v1.indd 199 5/9/12 11:56 AM
  • 200 nader et al. behavior change have led to leveling of the progression supportive environmental changes is the next logical step of overweight in targeted groups. Applying place-based in obesity prevention efforts. early life systems–oriented health behavior change inter- Combining simultaneous behavioral and environmental ventions combined with simultaneously implemented change marks a notable departure from existing single Table 2. Pathways for Early Life Systems Systems pathways framework (Figure 2) Examples of systems interactions 1.  olicies related to urban planning, housing, transportation, Increased access to safe places for physical activity using primary medical P parks and recreation, food availability, access, financing care “Rx for physical activity” honored by local recreation centers; and marketing, and education joint use agreements between parks and recreation and schools. 2.  olicies on media and information, housing P Policies on advertising to young children, WIC incentives for breastfeeding, (e.g., segregation), industry practices, labor, individual lactation support for working mothers; day care food and activity policies incentives (tax, insurance, etc.) and certification. 3.  olicies on healthcare infrastructure, financing, P Culturally relevant family behavior change programs, use of lay health outreach delivery mode educators connecting primary care and community prevention; institution of baby- friendly practices in birthing institutions and prenatal care; community prevention campaigns, surveillance and monitoring of population health outcomes (BMI). 4. nterplay between social and physical environment I Attempt to change social and physical environments through social networks and urban redevelopment to shift social norms and culture. 5.  ocial and physical environments that enable S Identify barriers and supports for families and provide tools to help them make and/or constrain family and individual behavior; small changes in their immediate environment. Individuals shaping their environment 6.  reventive and curative services to families and individuals Update pregnancy, postpartum, and pediatric clinical protocols to provide same P age-appropriate health messages and services to interconceptual and pregnant women, and postnatal nutrition and activity goals. 7.  ealthcare providers’ behaviors, policies, and practices, H Develop toolkits to equip providers with advocacy skills; provider training and as advocates for social and environmental changes on latest IOM/ACOG policies and health system guidelines; support provider to promote healthy lifestyles engagement with community agencies such as WIC, and child care providers. 8. ndividual empowerment and community mobilization I Use grassroots advocacy and civic participation to promote policy change. to effect policy change IOM, Institute of Medicine; ACOG, American Congress of Obstetricians and Gynecologists; WIC, Women, Infants and Children Program. Table 3. Strategies for Policy, Professional Behavior, and Public Education Supporting Individual and Family Health Behavior Changes for Pregnancy, Infancy, and Toddlers In addition to policies and built environments supporting safety, walkability, access to healthy foods and water, and active transportation Pregnancy Infancy Toddler •  aby-friendly policies in prenatal care B •  ork site and service site lactation W •  ay care food and activity policies D POLICY and birthing institutions support policies and certification •  reation of children’s zones to encourage C healthy behaviors • ncorporate most recent IOM/ACOG I •  onitor infant growth with appropriate M •  ay care and health provider D guidelines in prenatal/interconceptual care infant nutrition recommendations encouragement and reinforcement PROFESSIONAL •  onsistent health recommendations C •  rovider encouragement and P of family health behavior changes in food regarding breastfeeding and infant nutrition reinforcement of family activity behavior and snack choices, sweetened foods and from prenatal and postnatal health and home environment change, parenting, beverages, portion size, and screen time providers sleeping and infant soothing techniques •  rovider encouragement of daily activity/ P other than feeding play time •  rovider advocacy for work site lactation P •  rovider advocacy for healthy day care P support environments •  ommunity support systems for timely C •  ame current health messages from S •  ay care encouragement and modeling D EDUCATION prenatal care and breastfeeding preparation all infant care providers of changes in food and snack choices, •  ommunity support for and awareness C •  IC support and incentives to continue W sweetened foods and beverages, portion of maintaining a healthy maternal weight breastfeeding size, and screen time before, during, and after pregnancy •  ommunity systems support ability C •  amily and community resource centers F of families with infants to achieve a healthy reinforce same targeted health behaviors home environment IOM, Institute of Medicine; ACOG, American Congress of Obstetricians and Gynecologists; WIC, Women, Infants and Children Program.CHI 8.3 Jun 12 v1.indd 200 5/9/12 11:56 AM
  • childhood Obesity June 2012 201 modality approaches (behavior change only or environ- ing obesity epidemic. Currently, obesity-related diseases mental change only). Whitaker72 noted that traditional account for 10% of U.S. medical spending, or an estimat- research methods, such as the randomized trial, are lim- ed $147 billion/year. Estimates of medical costs associat- ited in addressing the complex factors involved in child- ed with treatment of obesity related diseases are projected hood obesity. The approach presented here uses systems to increase by $48 to $66 billion/year in the United States methods that take into account attitudes and norms in a by 2030.74 The National Institutes of Health (NIH) spent defined community, as well as the challenges imposed by $971 million in fiscal 2010 on obesity research. In 2010, broader societal values and physical, social, and institu- the CDC awarded $372.8 million to 44 communities for tional barriers to change. The public message would be “Communities Putting Prevention to Work” (CPPW) to promote well-being as opposed to avoiding poor health grants to improve nutrition and physical activity, reduce outcomes. For example, providing the best chances for a obesity, and prevent smoking. An additional $100 mil- healthy life for an expected offspring is likely to be more lion has been allocated for “Community Transformation valued by the average person than linking motivation Grants” to prevent chronic diseases and health disparities. for behavior changes to a distant goal of avoiding extra Funds for testing this approach could conceivably come weight because of increased risks for chronic disease later from prioritizing existing and planned funding streams in life. directed toward reducing the economic and health bur- To see if building early life systems–oriented solutions dens of a continuing obesity epidemic. Using a systems to obesity works, we propose a series of community- approach might eventually result in cost savings because driven, coordinated, place-based interventions that are of cost-efficiencies gained through coordination of exist- rigorously evaluated. Sites with experience in cross- ing policy and behavior change interventions and the sector collaboration, with strong research methodologists avoidance of redundancies, as well as rapid identification and community leadership and partnerships, would be and remedy of costly unintended consequences.75 selected through a competitive mechanism with national One of the first multilevel, multicomponent, school- oversight from a major public health research institu- based interventions to simultaneously address both tion. For example, selection of 8–10 specific communi- policy and behavioral interventions was the Child and ties reflecting diverse populations would implement and Adolescent Trial for Cardiovascular Health/Coordinated evaluate interventions tailored to the unique strengths and Approach to Child Health (CATCH) study. At that time constraints of participating local communities. The evalu- (1987–1996), multicomponent interventions were novel ation would combine the strengths of community-based to researchers. Today, there is substantial experience with participatory research with the rigor of the randomized policy (e.g., baby-friendly and lactation support policies) clinical trial. The interventions would be standardized, and health behavior intervention research (e.g., limiting but intentionally variable with regard to delivery meth- excessive gestational weight gain and early childhood ods, cultural tailoring, and real-world problem solving. interventions). What remains to be done is to implement Comparisons could be done with cluster randomization, and evaluate policy change and health behavior change or simulated through multiple baselines, or interrupted at the same time in the same place, using systems-based time series analyses in a single population. Iterations methods that include the interactions among individuals in several communities add validity to overall conclu- and environments. The current experience of U.S. com- sions of effectiveness. Standardized outcome measures munities that have already implemented environmental and analytical methods will be employed. Design and changes, such as those participating in CDC’s CPPW and oversight responsibilities are shared by research method- Community Transformation Grants, provides a pool of ologists and community leaders. This method has been communities that could be ready to implement and test suggested as a “multisite translational community trial” to this combined approach applied to the systems impacting test the real-world community efficacy of complex health early life. promotion interventions.73 The series of interventions would be evaluated by the outcomes of healthier weight for childbearing women and Conclusion their infants and young children. Follow-up should con- The approach proposed in this paper—to focus a new tinue long enough to track adult and child weights, and to effort on evaluating multiple place-based (defined com- document the sustainability, costs, and any demographic munity) systems-oriented interventions designed around changes over time. pregnancy, resulting in a healthy weight for women and Is it feasible to implement and evaluate this added their offspring—is intended to launch a discussion among emphasis to current obesity prevention efforts? Feasibil- private and public health practitioners and investigators, ity is linked to prioritization of financial resources, which leaders in maternal and child health, policy makers, gov- potentially contrasts the values of remaining with the sta- ernment agencies, and private foundations on the merits tus quo intervention and research methods, compared to of adding this approach to obesity prevention efforts. the costs of testing a broader paradigm and methods. Both Federal and private agency initiatives reflect a growing need to be referenced to the estimated costs of a continu- momentum to alter the systems that feed the continuationCHI 8.3 Jun 12 v1.indd 201 5/9/12 11:56 AM
  • 202 nader et al. of the obesity epidemic. We believe this is the next logical 11. Freedman DS, Ogden CL, Flegal KM, et al. Childhood overweight step in obesity prevention, built upon the tools and expe- and family income. MedGenMed. 2007;9:26. rience gained over the last 30 years and that the nation 12. ason M, Meleedy-Rey P, Christoffel KK, et al. Prevalence of M overweight and risk of overweight among 3- to 5-year-old Chicago could be prepared to take on this challenge. children, 2002-2003. J Sch Health 2006;76:104–110. 13. besity prevalence among low-income, preschool-aged chil- O dren—United States, 1998–2008. MMWR Morb Mortal Wkly Rep Acknowledgments 2009;58:769–773. The authors gratefully acknowledge: Natalia Veronique 14. Nader PR, O’Brien M, Houts R, et al. Identifying risk for obesity in early childhood. Pediatrics 2006;118:e594–e601. Lotz, medical student, Eastern Virginia Medical School, and 15. kinner AC, Steiner MJ, Henderson FW, et al. Multiple markers of S Matthew Cappiello, medical student, University of Cali- inflammation and weight status: Cross-sectional analyses through- fornia, San Diego School of Medicine, for their assistance out childhood. Pediatrics 2010;125:e801–e809. with literature review for this paper. We also appreciate 16. illman MW. Early infancy as a critical period for development of G the careful manuscript preparation and review by Christine obesity and related conditions. Nestle Nutr Workshop Ser Pediatr Williams, M.P.H., and Estela Blanco, M.P.H., M.A. In addi- Program 2010;65:13–20; discussion 20–14. tion, thanks to Melinda Bender, R.N., Ph.D., and Yvette 17. reedman DS, Khan LK, Serdula MK, et al. The relation of child- F La Coursiere, M.D., M.P.H., Assistant Clinical Professor, hood BMI to adult adiposity: The Bogalusa Heart Study. Pediatrics Department of Obstetrics and Gynecology, Reproductive 2005;115:22–27. 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