A consortium of 14 international research and advocacy organisations met in Oslo, Norway, 27-28 June 2018 to kick off the ground-breaking project CO-CREATE, to tackle overweight and obesity in young people. This is one of three presentations from the kick off meeting. The CO-CREATE project web site is http://www.co-create.eu

1. The Challenges of Childhood Obesity
Deanna M. Hoelscher, PhD, RDN, LD, CNS
June 27, 2018

2. Confronting obesity: Co-creating policy with youth
“I’m not sure I know what to eat”June 20, 2018
David Kessler, MD, JD
Former US FDA Commissioner
Challenges:
“Made fat, sugar, salt available 24/7 on every corner.”
We need to know more about the biologic basis of nutrition.
One viewpoint about diet and obesity...
Source: https://www.medpagetoday.com/primarycare/dietnutrition/73631

3. Confronting obesity: Co-creating policy with youth
Marion Nestle, PhD
Professor Emeritus,
New York University
3 major challenges for food & health beginning in the 1980’s:
Overproduced food that then needed to be sold
“Shareholder value movement” on Wall Street meant that companies needed to
show profits on a continual basis
Deregulated controls around marketing
Another viewpoint...
Source: https://www.medpagetoday.com/primarycare/dietnutrition/73631

4. Confronting obesity: Co-creating policy with youth
Childhood obesity
Increasing prevalence
108 million children are obese worldwide
Prevalence is less than in adults, but rate of increase is steeper
Obesity in childhood is likely to persist into adulthood
Lifetime of medical conditions and higher healthcare costs
Associated with chronic diseases such as type 2 diabetes, sleep disorders, and CVD risk
factors
Requires a population level focus
Requires a developmental focus
Needs a ‘healthy growth strategy’ focusing on diet and physical activity
Overview of Childhood Obesity
Source: GBD Obesity Collaborators, NEJM, 2017; Frelut et al., 2017; Rodgers et al., 2018;
Lobstein et al., Lancet, 2015

5. Confronting obesity: Co-creating policy with youth
Socioeconomic Differences in Trends in Overweight and
Obesity in Children and Adolescents (n = 30 studies)
Source: Chung et al., Obesity Reviews, 2016
NOTE: 30 total studies,
13 children & adolescent,
9 children, 8 adolescent;
No change is across all
sex subgroups, Widening/
Narrowing across some or
all sex groups.

6. Confronting obesity: Co-creating policy with youth
Causes
Individual choice
Environmental factors
Responsibility for action
Personal responsibility
Collective responsibility
Explanation of Consumption of
Unhealthy Foods
Upstream supply-side focus
Downstream demand focus
Regulation
Government regulation
Industry self-regulation
Drivers for change
Top-down (government)
Bottom-up (grassroots)
Solution?
Prevention
Treatment
Paradigms for Childhood Obesity
Source: Roberto et al., Lancet, 2015

7. Confronting obesity: Co-creating policy with youth
Address both Environments and Behaviors
Changed from a purely medical model to one which
draws from many different fields
Biology, medicine, psychology, economics, law,
architecture, pharmacology, urban design,
agriculture
Does the public understand this?
Both Prevention and Treatment
Current Scientific Thinking about Childhood Obesity
Source: Perry et al., IJBNPA, 2015; Dietz et al., Lancet, 2015;
Frelut, 2017; Roberto et al., Lancet, 2015

8. Confronting obesity: Co-creating policy with youth
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Parents/Families Individuals/Personal Healthcare Providers Communities Farmers Employers Restaurants Transportation
Groups
No Role
Major Role
How much of a role should each play in fighting the obesity problem in Texas? Texas
Legislator Health Perception Study, 2013
Scale: 1=no role, 2=minor role, 3=some role, 4=major role
Source: TX Health Perception Survey

9. Confronting obesity: Co-creating policy with youth
Many youth obesity prevention studies have been conducted
Small effects
Focus on school setting
Focus on elementary school students
Little dissemination of programs
Emphasized diet, PA, sedentary behavior, sleep
Most are “one size fits all”
WHO Global Action Plan for the Prevention and Control of Non-
Communicable Disease
NCD Global Monitoring Framework
What Has Been Done to Date?
Source: Baranowski & Taveras, 2018, Childhood Obesity; Lobstein et al., Lancet, 2015;
http://www.who.int/nmh/events/ncd_action_plan/en/

10. Confronting obesity: Co-creating policy with youth
Genetic factors
Epigenetics
Adipose tissue
Brain-gut-adipose tissue
interactions through neuro-
hormonal pathways
Metabolically active
Sleep
Circadian rhythms
CLOCK genes
Microbiome
Bioinformatics
Transmission from mother to
infant
Stress
Environmental contaminants
Lack of examining alternative
predisposing or contributing
factors, when they occur, and in
what subgroups
Biologic Factors
Source: Baranowski & Taveras, 2018; Ludwig, 2018; Frelut, 2017

11. Confronting obesity: Co-creating policy with youth
Identification of obesity, but few solutions
Availability of programs
Cost of treatment/prevention
Developmental factors
Gender differences
Multidisciplinary approach involving families &
environment
Role of parents
Gatekeepers for nutrition and physical activity
Clinical & Family Factors
Source: Hoelscher et al., Childhood Obesity, 2015; Dietz et al., Lancet, 2015

12. Confronting obesity: Co-creating policy with youth
Excessive caloric consumption
Dietary quality/patterns
Food choice architecture
Food systems, agriculture
Excessive marketing of foods
Widespread availability of unhealthy foods
Formulation of foods with emphasis on fat, sugar, salt
NOURISHING framework
Food environments, food systems, behavior-change communication
Food, Food Systems, & Dietary Intake
Source: Roberto et al., Lancet, 2015; WCRF International; BMJ Food for Thought issue, 2018,
https://www.bmj.com/food-for-thought

13. Confronting obesity: Co-creating policy with youth
50
25
4
82
41,7
6,7
146
3,03
16,6
8,3
1,3
21
0,43
0
20
40
60
80
100
120
140
AND Necessary Provided Food ads F&N ads
Hryear Minweek Minday
• Briggs, M., et. al, (2010). Position of the American Dietetic Association, School Nutrition Association, and Society for Nutrition Education: comprehensive school
nutrition services. Journal of nutrition education and behavior, 42(6), 360-71. Society for Nutrition Education.
• Kann, L., et. al, (2007). Health Education: Results from the School Health Policies and Programs Study 2006. The Journal of school health, 77(8), 408-34.
doi:10.1111/j.1746-1561.2007.00228.
7600 food ads/year
153 F&N/ year
How Much Nutrition Education is Enough?

14. Confronting obesity: Co-creating policy with youth
Engineering of physical activity out of daily life
Safe parks, playgrounds
Walkable/bikable environments
Lack of physical activity in and around schools
Increased use of electronic
devices
Sleep hygiene
Physical Activity/Sedentary Behaviors
63.5
31.2
20.8 21.5
36.0
68.8
79.2 78.5
0
10
20
30
40
50
60
70
80
90
2 4 8 11
No Yes
Do you have a computer, iPad, tablet, phone or gaming
Console in the room where you sleep?
Source: Frelut, 2017;Hoelscher et al., TX SPAN, 2015-2016;
Kohl et al., 2013

15. Confronting obesity: Co-creating policy with youth
Implemented at several levels
More innovative policies often at local levels
Political environment
Entrenched special interests/’business as usual’
Policymakers
“Health in all policies” approach
Need to address health disparities
Few studies using youth advocacy
Need for evaluation
Unintended consequences
Policies, Systems, and Environments
Source: Roberto et al., Lancet, 2015; Lobstein et al., 2015; Frelut, 2017; Ludwig, 2018

16. Confronting obesity: Co-creating policy with youth
Unintended Consequences

17. Confronting obesity: Co-creating policy with youth
Measurement/Evaluation
Assessment of body fat
Other methods? Waist circumference?
Dietary assessment
Assessment of physical activity
Assessment of sedentary behaviors
Cost effectiveness
Evaluation of policies and practices
Evaluation of marketing efforts
Source: Lobstein et al., Lancet, 2015; Hoelscher et al., ARPH, 2017; EPOP, 2013

18. Confronting obesity: Co-creating policy with youth
Source: Hoelscher et al.,
ARPH, 2017

19. Confronting obesity: Co-creating policy with youth
Summary & Next Steps
Childhood obesity is influenced by many factors
Challenges exist at several levels
Healthy environments and individual-level changes act in a reciprocal
manner
Policies, systems, environments 2.0
Relatively few successful intervention studies in adolescents
Youth advocacy
Evaluation is necessary to document successes, unintended
consequences, and next steps

20. Confronting obesity: Co-creating policy with youth
Thank you!
Tom Baranowski
Jaimie Davis
Molly Bray
Shreela Sharma
Steve Kelder
Amy Yaroch
Tiffni Menendez

21. Click to edit Master title style

22. The CO-CREATE project has received funding from the European Union’s
Horizon 2020 research and innovation programme under grant agreement No 774210.
The products of the research are the responsibility of the authors: the European
Commission is not responsible for any use that may be made of them.
www.co-create.eu

23. Confronting obesity: Co-creating policy with youth
References
Rogers et al., Amer J Prev Med 2018; 54(3):450-452.
Frelut. Dev Period Med 2017;XXI(3):177-178.
Baranowski & Taveras. Childhood Obesity 2018;14(1):1-3.
Roberto et al. Lancet 2015:385:2400-2409.
Ludwig. Pediatrics 2018;141(3)
Perry et al., IJBNPA, 2015.
Hoelscher et al. Annual Review of Pubic Health. 2017
Hoelscher et al., Environment & Behavior, 2016
Chung et al., Obesity Reviews, 2016
Lobstein et al., Lancet, 2015

24. Confronting obesity: Co-creating policy with youth
Contact information
Deanna M. Hoelscher, PhD, RDN, LD
Director, Michael & Susan Dell Center for Healthy Living
University of Texas Health Science Center at Houston (UTHealth) School of
Public Health - Austin Campus
Deanna.M.Hoelscher@uth.tmc.edu | 512.391.2510
@deannahoelscher

25. Confronting obesity: Co-creating policy with youth
Trends in Child Obesity in Texas, TX SPAN (2000-2016)
Percentofstudents
0
5
10
15
20
25
30
2000-2002 2004-2005 2009-2011 2015-2016
Grade 4 Grade 8 Grade 11
Healthy
People 2020
Goal, 14.5%
* *
*marginally significant
Source: Hoelscher, TX SPAN, 2015-2016