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John Foreyt Presentation - Global Experience in Building Sustainable Healthy Communities: Overview from USA

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Foreyt day1 pl3

  1. 1. Global Experience in BuildingSustainable Healthy Communities: Overview from USA Community Health and Wellbeing Through Multi-Sectoral Partnerships Blacktown, NSW, Australia 6 December, 2011 John P. Foreyt, Ph.D. Baylor College of Medicine Houston, TX jforeyt@bcm.edu
  2. 2. Increasing prevalence of obesity worldwideBetween 1980 & 2008, the mean BMIworldwide increased by 0.4 kg/m² per decadefor men and 0.5 kg/m² for womenIn 2008, 1.46 billion adults worldwide wereoverweight or obeseOf these, 205 million men (9.8%) and 297million women (13.8%) were obese Finucane et al, Lancet, 2011
  3. 3. Increasing prevalence of obesity in USAIf the present trend is not halted, it is projected that by the year 2030 86.3% of adults in the United States will be overweight or obese. Wang, Beydoun, Liang, et al. Obesity, 2008
  4. 4. Sectors of Society Science & Arts & Technology Entertainment CommerceLaw & Politics & Trade Healthcare Education Family/ Community
  5. 5. Law and Politics “Let’s Move!” Campaign "In the end, as First Lady, this isn’t just a policy issue for me. This is a passion. This is my mission. I am determined to work with folks across this country to change the way a generation of kids thinks about food and nutrition."
  6. 6. EducationNational School Lunch Program
  7. 7. Commerce and Trade Farmers’ Markets
  8. 8. Science & TechnologyWiiFitX-boxKinectNike runHealthBlogsPhone Apps
  9. 9. Arts and Entertainment
  10. 10. Family/Community Walking School Bus walk to "Kids used to school all the time," Whatley says. "Now, its almost impossible." And with childhood obesity rates on the rise, Whatley says walking is important because its the "easiest way to exercise for a lifetime."
  11. 11. Health Care
  12. 12. Results of Lifestyle Interventions for Weight Loss“Those who complete weight-loss programs lose approximately 10% of their body weight, only to regain two-thirds of it back within one year and almost all of it back within 5 years”Institute of Medicine. Weighing the options: Criteria for evaluating weight management programs. 1995
  13. 13. Results of Lifestyle Interventions for Weight LossWeekly group sessions over 4 – 6 monthsMean post-treatment weight reductions of ~8-10%Attrition rates are high at 2-yrs (mean =39%, range 20-65%)Attrition rates beyond 2-yrs (mean = 65%) Perri, Foreyt, & Anton. Preventing Weight Regain After Weight Loss. 2008.
  14. 14. Results of Lifestyle Interventions: Pattern of Weight RegainWeight regain occurs steadily over 2-5 yrsLong-term follow-ups of behavioralinterventions show a reliable pattern ofgradual regaining of lost weightLong-term losses of ≥ 5 Kg are sustained inless than 20% of patients in behavioraltreatment Perri, Foreyt, & Anton. Preventing Weight Regain After Weight Loss. 2008.
  15. 15. Results of Lifestyle Interventions: Pattern of Weight Regain“The difficulty associated with maintaining lost weight appears to be the result of physiological, environmental, and psychological factors that combine to facilitate a regaining of lost weight and an abandonment of weight control efforts.” Perri, Foreyt, & Anton, 2008.
  16. 16. Population-wide prevention of obesitySmall changes in diet and physical activity may make more sense than focusing on large behavioral changesBy cutting 100 calories a day, adults can prevent weight gain Hill et al, Science, 2003; Hill, AJCN, 2009
  17. 17. BENEFITS OF MODEST WEIGHT LOSS “Several studies demonstrate that small losses…helpreduce obesity-related co-morbidities and thatimprovements in these risk factors persist withmaintenance of these modest weight losses.” Institute of Medicine, 1995-  Glucose levels -  HDL cholesterol levels-  Insulin levels -  LDL cholesterol levels-  Glycated hemoglobin -  Blood pressure-  Triglyceride levels -  Quality of life levels
  18. 18. Stigmatization & DiscriminationSocietal beliefs that weight can becontrolled, thereby suggestive ofcharacter deficits (lack of willpower,laziness, and emotional problems)Negative attitudes“Last safe prejudice” in U.S. society Rand CSW, Macgregor AMC. South Med J. 1990.
  19. 19. DISCRIMINATION: THE PAIN OF OBESITYFormer severely obese patients: 100% preferred to be deaf, dyslexic, diabetic or have heart disease or bad acne than to be obese again Leg amputation was preferred by 91.5% and blindness by 89.4% 100% preferred to be a normal weight person rather than a severely obese multi-millionaire Rand CSW, Macgregor AMC. Int J Obes. 1991;15:577–579.
  20. 20. Psychosocial Burden of ObesityObese individuals often feelmisunderstood, neglected, and rejectedObese individuals have low employmentprospects, and are denied educational,vocational, and advancementopportunitiesSignificantly poorer quality of life van Hout GCM., van Oudheusden I., & van Heck GL. Obes. Surg. 2004
  21. 21. Building Sustainable Healthy Communities: Healthy LifestyleA Healthy Lifestyle is All About Balance: Healthy Diet Healthy Physical Activity
  22. 22. Building Sustainable Healthy Communities: Healthy LifestyleUNFORTUNATELY…
  23. 23. Big Texan Steak Ranch Amarillo, Texas72-oz Steak FREE if eaten within 1 hour
  24. 24. AVERAGE ADULT AMERICAN MAN Height: 5’ 8” Weight: 195 lbs Waist: 39.7 in. BMI: 28.4 CDC, 2011
  25. 25. AVERAGE ADULT AMERICAN WOMAN Height: 5’3” Weight: 165 lbs Waist: 37.0 in. BMI: 26.1 CDC, 201
  26. 26. Miss America,2008Kirsten HaglundBMI: 16.29
  27. 27. Eliana RamosAge: 18Height: 5’9”
  28. 28. 29th OLYMPIAD BEIJING, CHINAUS wrestling team captain, DanielCormier (211.5 lbs), hospitalized forkidney failure as result ofdehydration related to cutting weight(did not compete).US boxer, Gary Russell was foundunconscious 4 days before hisOlympic bout due to cutting weight(did not compete).
  29. 29. 29th OLYMPIAD BEIJING, CHINA Michael Phelps 8 Gold Medals, SwimmingAge: 23Height: 6’4”Weight: 195 lbsBMI: 23.74Daily Food Intake: 10,375 KCAL (15% PRO, 58% CHO, 27% FAT)Exercise: 30 hrs/wk
  30. 30. 2005: USDA FOOD PYRAMID“The food pyramidis too complicatedand has too manymessages.”Robert Post, PhD. USDA DeputyDirector, 2011
  31. 31. 2005: USDA FOOD PYRAMID“It’s going to be hard not to do better than the current pyramid, which basically conveys no useful information.” Walter C. Willett, M.D. Chairman, Department of Nutrition Harvard School of Public Health
  32. 32. 2011: USDA MY PLATE“We are allbombarded with somany dietarymessages that it ishard to find time tosort through all thisinformation.”Michelle Obama, 2011
  33. 33. Dietary Guidelines for Americans 2010: Two Primary ConceptsMaintain calorie balance over time toachieve and maintain a healthy weightFocus on consuming nutrient-dense foodsand beverages Dietary Guidelines for Americans, 2010
  34. 34. Efficacy-based comparative dietary guidelines Carb% Fat% Pro% Mediterranean Diet 45-55 25-35 20 IOM Dietary Ref. Intakes 45-65 25-35 15 NCEP-ATPIII 50-60 25-35 15 Am. Dietetic Assoc. 45-65 20-35 15
  35. 35. PARADOX OF INCREASING OBESITY PREVALENCE•  Focus on healthy eating and physical activity•  Awareness of dangers of obesity, but…• Obesity prevalence continues to rise • Work & commuting demands • Little time to exercise • Little time to prepare food • Availability of high-fat/calorie foods
  36. 36. Rationale for community-based interventions• Increases in obesity prevalence due to genes? • Increased calories (e.g., 200 Kcal/day over 10 years) • Increased portion sizes (e.g., 22 oz. steaks and 44 oz. sodas) • Western diets in developing nations increase risk of obesity
  37. 37. READINESS TO CHANGE“Habit is habit, and not to beflung out of the window, butcoaxed downstairs a step at atime.” Mark Twain
  38. 38. Long-Term Weight MaintenanceNational Weight Control Registry (N=10,000)Survey of 3,000 members who have been in theRegistry for at least 10 yearsStarting weight = 224 lbs; Average weight loss=69lbs.At 5 years, participants had maintained an averageweight loss=52 lbs.At 10 years, participants had maintained an averageweight loss=51 lbs. Thomas, Bond, Phelan et al., TOS, 2011
  39. 39. Long-Term Weight MaintenanceWeight Maintainers report that they usually: Track their food intake Count calories or fat grams Follow a low-calorie, low fat diet (1,800 calories/day; less than 30% of calories from fat Eat breakfast regularly Limit the amount they eat out (about 3 times/week; eat fast food less than once/week) Thomas, Bond, Phelan et al., TOS, 2011
  40. 40. Long-Term Weight MaintenanceWeight Maintainers report that they usually: Eat similar food regularly Don’t splurge much on holidays & special occasions Walk about one hour/day Watch less than 10 hours of TV a week Weigh themselves at least once a week Thomas, Bond, Phelan et al., TOS, 2011
  41. 41. LONG-TERM WEIGHT MAINTENANCEContinued consumption of a low-calorie diet with moderate fat intakeLimited fast foodHigh levels of physical activity Phalen et al, Obesity 2006; 14: 710-716
  42. 42. LONG-TERM WEIGHT MAINTENANCE"Daily weighing improved maintenance of weight loss, particularly when delivered face to face." Wing et al, NEJM 2006; 355:1563-1571
  43. 43. Most Promising Strategies For Preventing Weight Regain Providing multi-component programs with ongoing professional contacts Physical activity/exercise Portion control/meal replacements Extending treatment through weekly or bi-weekly sessions Pharmacotherapy Perri, Foreyt, & Anton. Preventing Weight Regain After Weight Loss. 2008.
  44. 44. Most Promising Strategies For Preventing Weight RegainExtended treatments have shownpromise in promoting adherence tothe behaviors required for the long-term maintenance of weight lossContinuous care approach, focusedon reasonable long-term objectives,appears appropriate for mostpatients Perri, Foreyt, & Anton. Preventing Weight Regain After Weight
  45. 45. An Example of a successful long-term intervention: The Look AHEAD Study Does Weight Loss ReduceCardiovascular Disease and Death inOverweight Individuals with Diabetes?
  46. 46. Look AHEAD• Action for HEAlth in Diabetes• Objective: to examine in overweight persons with Type 2 Diabetes, the long- term effects of an intensive lifestyle intervention program compared to diabetes education and support.• 16 Centers• 5145 overweight volunteers with diabetes
  47. 47. Look AHEAD Primary End Point Composite• Cardiovascular death (including fatal myocardial infarction and stroke)• Non-fatal myocardial infarction• Non-fatal stroke
  48. 48. Clinical Sites Seattle Boston Minneapolis Providence New York Pittsburgh Philadelphia Baltimore Denver Winston-Salem Memphis PhoenixLos Angeles Birmingham Houston San Antonio Baton Rouge Clinical Site Coordinating Center
  49. 49. Look AHEAD Participants Lifestyle DSE (N=2630) (N=2574)Women 59% 60%Minority 37% 37%Age (years) 58.6 58.9Insulin Users 14% 15%Baseline BMI 35.9 36.0Baseline weight (kg) 100 101Attended 1 year exam 96% 94%* * p < .0004
  50. 50. Look AHEAD Study Interventions• Diabetes support and education - DSE (control group)• Lifestyle intervention – ILI (treatment group)
  51. 51. Look AHEAD Lifestyle InterventionGoals: • 7% weight loss for the group (10% for individual) • 175 minutes of moderate intensity activity
  52. 52. Look AHEAD Lifestyle Intervention• Diet – ADA, NCEP (< 30% fat, < 10% sat fat, >15% protein) – 1200-1500 (if weight <250lbs) – 1500-1800 (if weight >250lbs) – During first 4 weeks to 4 months, portion control (liquid meal replacements or structured meal plan)
  53. 53. Look AHEAD Lifestyle Intervention• Physical Activity – unsupervised – 175 minutes moderate intensity/week – 5 days/week – walking
  54. 54. % Weight Loss at 1-Year ILI DSE 0 -1% Weight Change 0.7% -2 -3 -4 p < 0.0001 -5 -6 -7 -8 -9 8.6% The Look AHEAD Research Group, Diabetes Care, 2007
  55. 55. % Reduction in Initial Weight by Gender % Reduction in Initial Weight 0 Men -2 Women -4 -6 N=1229 N=1197 -8 P<0.001 -10 N=872 N=830 -12 0 2 4 6 8 10 12 Months The Look AHEAD Research Group, Diabetes Care, 2007
  56. 56. Fitness Change (%) at 1-Year 25 20.9Mean % Fitness Change 20 15.9 15 10.8 10 5.8 5 0 DSE ILI DSE ILI Unadjusted Adjusted for 1 Year P<0.001 Weight Change P<0.001 The Look AHEAD Research Group, Diabetes Care, 2007
  57. 57. 1-Year Changes in Markers of Diabetes Control Markers of Diabetes Control ILI DSE P-valueHemoglobin A1c (%), BL 7.25 7.29 0.26Hemoglobin A1c (%), Y1 6.61 7.15 <0.001Y1 – Baseline -0.64 -0.14 <0.001Fasting glucose (mg/dl), BL 151.9 153.6 0.21Fasting glucose (mg/dl), Y1 130.4 146.4 <0.001Y1 – Baseline -21.5 -7.2 <0.001Diabetes medications, BL 86.5% 86.5% 0.93Diabetes medications, Y1 78.6% 88.7% <0.001Y1 – Baseline -7.8% 2.2% <0.001
  58. 58. 1-Year Changes in Markers of Blood Pressure ControlMarkers of Blood Pressure Control ILI DSE P-valueSystolic BP (mmHg), BL 128.2 129.4 0.26Systolic BP (mmHg), Y1 121.4 126.6 <0.001Y1 – Baseline -6.8 -2.8 <0.001Diastolic BP (mmHg), BL 69.9 70.4 0.11Diastolic BP (mmHg), Y1 67.0 68.6 <0.001Y1 – Baseline -3.0 -1.8 <0.001Antihypertensive medications, BL 75.3% 73.7% 0.23Antihypertensive medications, Y1 75.2% 75.9% 0.54Y1 – Baseline -0.1% 2.2% 0.02
  59. 59. 1-Year Changes in Markers of Lipid Control Markers of Lipid Control ILI DSE P-valueLDL-cholesterol (mg/dl), BL 112.2 112.4 0.78LDL-cholesterol (mg/dl), Y1 107.0 106.7 0.74Y1 – Baseline -5.2 -5.7 0.49HDL-cholesterol (mg/dl), BL 43.5 43.6 0.80HDL-cholesterol (mg/dl), Y1 46.9 44.9 <0.001Y1 – Baseline 3.4 1.4 <0.001Triglycerides (mg/dl), BL 182.8 180.0 0.38Triglycerides (mg/dl), Y1 152.5 165.4 <0.001Y1 – Baseline -30.3 -14.6 <0.001Lipid lowering medications, BL 49.4% 48.4% 0.52Lipid lowering medications, Y1 53.0% 57.8% <0.001Y1 – Baseline 3.7% 9.4% <0.001
  60. 60. 1-Year Changes in Percent of Participants Meeting ADA Goals ADA Goal ILI DSE P-valueHemoglobin A1c < 7%, BL 46.3% 45.4% 0.50Hemoglobin A1c < 7%, Y1 72.7% 50.8% <0.001Y1 – Baseline 26.4% 5.4% <0.001Blood pressure < 130/80 mmHg, BL 53.5% 49.9% 0.01Blood pressure < 130.80 mmHg, Y1 68.6% 57.0% <0.001Y1 – Baseline 15.1% 7.0% <0.001LDL-cholesterol < 100 mg/dl, BL 37.1% 36.9% 0.87LDL-cholesterol < 100 mg/dl, Y1 43.8% 44.9% 0.45Y1 – Baseline 6.7% 8.0% 0.34All three goals, BL 10.8% 9.5% 0.13All three goals, Y1 23.6% 16.0% <0.001Y1 – Baseline 12.8% 6.5% <0.001
  61. 61. Mean Changes in Weight, Fitness & BP Averaged Over Four Years DSE ILI P-value Mean MeanWeight Loss -0.88 -6.15 < 0.0001(% initial wt)Fitness 1.96 12.74 <0.0001(% METS)HbA1c -0.09 -0.36 < 0.0001SBP (mm Hg) -2.97 -5.33 < 0.0001DBP (mm Hg) -2.48 -2.92 0.012 Look AHEAD Research Group, Arch Int Med, 2010.
  62. 62. Mean Changes in Lipid Profile Averaged Over Four Years DSE ILI P-value Mean MeanHDL (mg/dl) 1.97 3.67 <0.0001TG (mg/dl) -19.75 -25.56 0.0006LDL (mg/dl) -12.84 -11.27 0.009LDL (mg/dl) -9.22 -8.75 0.42(Adjusting formedication use) Look AHEAD Research Group, Arch Int Med, 2010.
  63. 63. Percent (%) Completing Outcome Measures at Years 1-4Intervention Group Comparison Group(ILI) (DSE)Year 1 97.1 Year 1 95.7Year 2 94.9 Year 2 93.5Year 3 94.0 Year 3 93.8Year 4 94.1 Year 4 93.1
  64. 64. Look AHEAD SummaryILI had significantly greater improvementsthan DSE in all CVD risk factors averagedacross 4 years (except LDL-C)There may be long-term beneficial effectsfrom this 4-year period in which ILI subjectshave been exposed to lower CVD risk factorsLonger follow-ups will determine whetherthese lowered CVD risk factors can bemaintained & whether lifestyle interventionhas positive effects on CVD morbidity &mortality
  65. 65. Mary J.FemaleWhite56 years old at start of Look AHEADstudyPast Medical History: Type 2 diabetes,overweight, diverticulosis, arthritis,sleep apnea, back pain
  66. 66. Mary J.•Long term struggles: • Helping youngest daughter with personal issues and children • Rotator cuff problems • Degenerative disks in back • Rheumatoid arthritis • Diabetes • Physically demanding job • Financial struggles
  67. 67. 8/2007: grandkids enter pre-Pounds school Years
  68. 68. Catherine L.FemaleWhite47 years old at start of Look AHEADstudyPast Medical History: Type 2 diabetes,overweight, high blood pressure,hypothyroidism, back pain
  69. 69. Catherine L.Long term struggles:• Mother’s declining health and death• Multiple serious injuries• Sudden death of sister• Death of step-father• Declining economy• Children living at home
  70. 70. PoundsYears
  71. 71. Realistic Management Goals 5-10% weight loss Health, energy and fitness Well-being and self-esteem Mood and appearance Functional and recreational activity
  72. 72. Key ElementsFocus on health and energyFood and physical activity diariesGradual increase in physical activityGradual reduction in dietary fatNo feelings of food deprivationSocial support groups
  73. 73. Recommended Strategies for Building Sustainable Healthy Communities: Overview from USAPromote the availability of affordable healthyfood and beveragesSupport healthy food and beverage choicesEncourage breastfeedingEncourage physical activity or limit sedentaryactivity among children & youthCreate safe communities that support physicalactivityEncourage communities to organize for change
  74. 74. Recommended Community StrategiesStrategies to Promote the Availability of Affordable Healthy Food and Beverages Increase the availability of healthier food and beverage choices in public service venues (e.g., schools, city & county buildings, etc.)--Insufficient evidence in school-based programs--Associations suggest availability & increased consumption
  75. 75. Recommended Community StrategiesStrategies to Promote the Availability of Affordable Healthy Food and Beverages Improve availability of affordable healthier food & beverage choices in public service venues--Reducing the cost of healthier foods increases their purchase--Providing coupons redeemable for healthier foods increases their purchase
  76. 76. Recommended Community StrategiesStrategies to Promote the Availability of Affordable Healthy Food and Beverages Improve geographic availability of supermarkets in underserved areas-- Greater access to nearby supermarkets is associated with healthier eating behaviors-- Increasing the number of supermarkets in underserved neighborhoods increased real estate values, increased economic activity & employment, & resulted in lower food prices
  77. 77. Recommended Community StrategiesStrategies to Promote the Availability of Affordable Healthy Food and Beverages Provide incentives to food retailers to locate in and/or offer healthier food choices in underserved areas-- Presence of retail venues that provide healthier foods is associated with better nutrition-- Greater availability of supermarkets was associated with lower adolescent BMI scores
  78. 78. Recommended Community StrategiesStrategies to Promote the Availability of Affordable Healthy Food and Beverages Improve availability of mechanisms for purchasing foods from farms--Evidence supporting a direct link between purchasing food from farms & improved diet is limited--Two studies of initiatives to encourage participation in farmers’ market showed increased intention to eat more fruits & vegetables but no direct evidence
  79. 79. Recommended Community StrategiesStrategies to Promote the Availability of Affordable Healthy Food and Beverages Provide incentives for the production, distribution, and procurement of foods from local farms--No evidence has been published to link local food production & health outcomes--There is a current study exploring the potential nutritional & health benefits of eating locally grown foods
  80. 80. Recommended Community StrategiesStrategies to Support Healthy Food and Beverage Choices Restrict availability of less healthy foods & beverages in public service venues--No peer-reviewed studies examined the impact designed to restrict availability of less healthy foods in public service venues--21 states have policies that restrict the sale of competitive foods in schools beyond USDA regulations; however, no studies have evaluated the impact of the policies
  81. 81. Recommended Community StrategiesStrategies to Support Healthy Food and Beverage Choices Institute smaller portion size options in public service venues--Evidence is lacking to demonstrate effectiveness of population-based interventions aimed at reducing portion sizes in public service venues--Evidence from clinical studies in laboratories demonstrates decreasing portion sizes decreases energy intake
  82. 82. Recommended Community StrategiesStrategies to Support Healthy Food and Beverage Choices Limit advertisements of less healthy foods & beverages--Little evidence is available regarding the impact of restricting advertising on purchasing & consumption of less healthy foods--Cross-sectional time-series studies of tobacco- control efforts suggest an association between advertising bans & decreased tobacco consumption
  83. 83. Recommended Community StrategiesStrategies to Support Healthy Food and Beverage Choices Discourage consumption of sugar-sweetened beverages--One longitudinal study of a school-based intervention among Native-American high school students showed a substantial reduction in sugar-sweetened beverages over a 3-year period--A RCT of a home-based intervention that eliminated sugar-sweetened beverages showed reduction in BMI scores
  84. 84. Recommended Community Strategies Strategies to encourage breastfeeding Increase support for breastfeeding--Evidence directly linking environmental interventions that support breastfeeding with obesity-related outcomes is lacking--Epidemiologic studies indicate that breastfeeding helps prevent pediatric obesity
  85. 85. Recommended Community StrategiesStrategies to encourage physical activity or limit sedentary activity among children and youth Require physical education in schools--14 studies have demonstrated that school-based PE was effective in increasing levels of physical activity and improving physical fitness--Minimum of 150 min/wk in elementary schools, 225 min/wk in middle schools and high schools throughout the school year as recommended by NASPE
  86. 86. Recommended Community StrategiesStrategies to encourage physical activity or limit sedentary activity among children and youth Increase opportunities for extracurricular physical activity--Participation in after-school programs increased students’ level of physical activity & improved obesity-related outcomes (improved CV fitness, reduced body fat)--2 pilot studies providing extracurricular physical activity showed increased levels of PA & decreased sedentary behavior
  87. 87. Recommended Community StrategiesStrategies to encourage physical activity or limit sedentary activity among children and youth Reduce screen time in public service venues--A school-based RCT indicated that children who reduced their television, videotape, & video game use had significant decrease in BMI, tricep skin fold thickness, & waist circumference compared to controls--Spending less time watching television is associated with increased physical activity
  88. 88. Recommended Community StrategiesStrategies to create safe communities that support physical activity Improve access to outdoor recreational facilities--Review of 108 studies indicated that access to facilities and programs for recreation near their homes, & time spent outdoors, correlated positively with increased physical activity among children& adults--Perceptions that footpaths are safe for walking was significantly associated with adults being classified as physically active at a level sufficient for health benefits
  89. 89. Recommended Community StrategiesStrategies to create safe communities that support physical activity Enhance infrastructure supporting bicycling--Longitudinal intervention studies have demonstrated that improving bicycling infrastructure is associated with increased frequency of bicycling--Cross-sectional studies indicated a significant association between bicycling infrastructure & frequency of biking
  90. 90. Recommended Community StrategiesStrategies to create safe communities that support physical activity Enhance infrastructure supporting walking--Reviews of cross-sectional studies of environmental correlates of physical activity & walking generally find a positive association between infrastructure supportive of walking & physical activity--Identifying & creating safe routes to school, together with educational components, increased the number of students walking to school
  91. 91. Recommended Community StrategiesStrategies to create safe communities that support physical activity Locating schools within easy walking distance of residential areas--Community-scale urban design & land use policies & practices, including locating schools, stores, workplaces, & recreation areas close to residential areas, are effective in facilitating an increase in levels of physical activity--Majority of efforts to encourage walking to school involve improving the routes rather than improving the location of schools
  92. 92. Recommended Community StrategiesStrategies to create safe communities that support physical activity Improve access to public transportation--Insufficient evidence exists to determine effectiveness of transportation policies in increasing the level of physical activity or improving fitness--1 study indicated that 29% of individuals who walk to and from public transit achieve at least 30 minutes of daily physical activity
  93. 93. Recommended Community StrategiesStrategies to create safe communities that support physical activity Zone for mixed-use development--Allows residential, commercial, institutional, & other public land uses to be located in close proximity to one another--Studies using correlation analyses & regression models indicated that mixed land use was associated with increased walking & cycling
  94. 94. Recommended Community StrategiesStrategies to create safe communities that support physical activity Enhance personal safety in areas where persons are or could be physically active--Cross-sectional studies have demonstrated a negative relationship between crime rates and/or perceived safety & physical activity in neighborhoods--Few intervention studies have evaluated the impact of policies & practices to improve personal safety on physical activity
  95. 95. Geospatial Mapping: Linking Urban Environments to Health RiskMeasure association betweenenvironmental variables & healthrisk factorsAssess relationships betweenvariables at different levels ofanalysisUsed in conjunction with linearanalyses
  96. 96. Our Community Environmental Model of ObesityCommunity Factors Individual Factors Poverty Dietary Intake Crime Physical Activity Grocery Quality Genetics Restaurants Family History Weight Parks Stress/Coping Sidewalks Eating Disorders Status Fast Food Outlets Psychological Recreational Problems Facilities
  97. 97. Chosen NeighborhoodsCensus-block groups in the metro KansasCity area (Missouri) were identified based ona median income split (i.e., low and highincome) and mappedWe then matched census-block groups withinthe income groups by population density andpercentage of minority representationOne matched block group per income levelwas randomly selected
  98. 98. Prevalence of Obesity in Block-Groups* *Age-standardized to the 1990 U.S. CensusAge-adjusted Obesity Prevalence (%) 50 45 40 35 30 25 20 15 10 5 0 High-Income Low-Income
  99. 99. Density of Environmental Factors in the Community Contributes to a “Toxic” Obesity Environment 18 16 Density/1,000 persons 14 12 10 8 6 4 2 0 Fast-food Convenience Store Bars High-Income Low-Income
  100. 100. COMMUNITY’S PERCEPTION OF SAFETY Somewhat Safe or Unsafe 40 Percent (%) Feeling 35 30 25 20 15 10 5 0 Daytime Nighttime Low-Income High-Income
  101. 101. Percent Substandard (or worse) Housing or Ground Conditions of Residential Properties 30 Percent (%) 20 10 0 Structural Grounds Low-Income High-Income
  102. 102. CONCLUSIONSThese data suggest that the higherfrequency of outlets providingcalorically-dense foods and alcohol maycontribute to greater obesity prevalencein residents of low-income communitiesMore research is needed to thoroughlydocument environmental determinantsof health and obesity
  103. 103. Neighborhoods, Obesity, and Diabetes: A Randomized Social ExperimentFrom 1994-1998, HUD randomly assigned4,498 women with children living in publichousing in high-poverty urban censustracts to one of three groups: (1) housingvouchers redeemable only if they movedto a low-poverty census tract; (2)unrestricted vouchers; or (3) control group(no vouchers) Ludwig et al, NEJM, 2011:365;16
  104. 104. Neighborhoods, Obesity, and Diabetes: A Randomized Social Experiment10-12 year follow-up showed modest butpotentially important reductions in theprevalence of extreme obesity & diabetes in thegroup moving from a neighborhood with highpoverty on one of low poverty compared to thecontrol groupNo differences between the group receivingtraditional vouchers & the control group“Neighborhoods matter” Ludwig et al, NEJM, 2011:365;16
  105. 105. Recommended Community StrategiesStrategies to create safe communities that support physical activity Enhance traffic safety in areas where persons are or could be physically active--Community-scale urban design & land use policies to promote physical activity, including design components to improve street lighting, infrastructure projects to increase safety of pedestrian street crossing, and use of traffic calming approaches such as speed humps & traffic circles are effective in increasing physical activity--Both community-scale & street-scale policies & practices are effective in increasing physical activity
  106. 106. Recommended Community Strategies Encourage Communities to Organize for Change Participate in community coalitions or partnerships to address obesity--Little evidence is available to determine the impact of community coalitions on obesity prevention--The presence of anti-smoking community coalitions has been associated with lower rates of tobacco consumption
  107. 107. What is the US Government doing?Community Transformation Grants (CTG) to States and Communities$103 million awarded to 61 states andcommunities, including state & local governmentagencies, tribes & territories, & state & local non-profit organizationsTo build capacity to implement changes forcommunity prevention efforts to ensure long-term successTo implement evidence-based and practice-based programs to improve health & wellness www.cdc.gov/10/5/2011
  108. 108. What is the US Government doing? Community Transformation Grants (CTG) to States and CommunitiesPriority areas are: Tobacco-free living Active living and healthy eating Evidence-based quality clinical and other preventive health services for prevention and control of high blood pressure and high cholesterol www.cdc.gov/10/5/2011
  109. 109. What is the US Government doing?Community Transformation Grants (CTG) to States and CommunitiesApplicants proposed specific activities inline with their chosen priority areas in theirapplicationsGrantee activities will not be finalized untilplans are negotiated with CDC by early2012 www.cdc.gov/10/5/2011
  110. 110. What is the US Government doing? Community Transformation Grants (CTG) to States and CommunitiesExample of Capacity-Building Award: The Confederated Tribes of The Chehalis Reservation is receiving a $498,663 planning award to build capacity to support healthy lifestyles among their tribal population of 1,500 in Washington State. Work will target tobacco-free living, active living and healthy eating, and quality clinical and other healthy services www.cdc.gov/10/5/2011
  111. 111. What is the US Government doing? Community Transformation Grants (CTG) to States and CommunitiesExample of Implementation Award: Austin, TX, Dept of Health and Human Services is receiving $1,026,158 to serve Travis County (Austin) to expand efforts in tobacco-free living, active living and healthy eating, quality clinical and other preventive services, social and emotional wellness and healthy and safe physical environments www.cdc.gov/10/5/2011
  112. 112. Building sustainable healthy communities: Bottom lineObesity is an environmental problemDespite progress in genetic research, public healthadvances only will occur when we take theenvironment seriouslyAcknowledging the role of the environment in theetiology of obesity will help us stop focusing on theindividual, which is encouraged by genetic andbiological explanations, and begin focusing onchanging the toxic environmentUntil we do this, we will not make substantialprogress in addressing the epidemic of obesity Poston & Foreyt, Atherosclerosis, 1999
  113. 113. What’s the best approach?Integrate all sectors of society into community change interventionsIncorporate: Sectors of Society Science & Technology Science & Arts & Education Technology Entertainm ent Family/Community Healthcare Law & Commerce Politics & Trade Arts & Entertainment Law & Politics Commerce & Trade Healthcare Education Family/ Community
  114. 114. Project FIT: rationale, design and baseline characteristics of a school- and community-based intervention to address physical activity and healthy eating among low-incomeelementary school children.Eisenmann JC, Alaimo K, Pfeiffer K, Paek HJ, Carlson JJ, Hayes H, Thompson T, Kelleher D,Oh HJ, Orth J, Randall S, Mayfield K, Holmes D.SourceDepartment of Kinesiology, Michigan State University, East Lansing, MI, USA. jce@msu.eduAbstractBACKGROUND:This paper describes Project FIT, a collaboration between the public school system, localhealth systems, physicians, neighborhood associations, businesses, faith-based leaders,community agencies and university researchers to develop a multi-faceted approach topromote physical activity and healthy eating toward the general goal of preventing andreducing childhood obesity among children in Grand Rapids, MI, USA.METHODS/DESIGN:There are four overall components to Project FIT: school, community, social marketing, andschool staff wellness - all that focus on: 1) increasing access to safe and affordable physicalactivity and nutrition education opportunities in the schools and surrounding neighborhoods; 2)improving the affordability and availability of nutritious food in the neighborhoods surroundingthe schools; 3) improving the knowledge, self-efficacy, attitudes and behaviors regardingnutrition and physical activity among school staff, parents and students; 4) impacting theculture of the schools and neighborhoods to incorporate healthful values; and 5) encouragingdialogue among all community partners to leverage existing programs and introduce newones.
  115. 115. Building sustainable healthy communities“The Current Epidemics of Chronic Diseases are a Result of Discordance Between Our Ancient Genes and Modern Lifestyle.” Eaton et al., The Paleolithic Prescription. 1988.
  116. 116. Building sustainable healthy communities “Accuse not nature. She has done her part. Do Thou but Thine.” John Milton (1687), Paradise Lost
  117. 117. SECRETS OF SUCCESSFUL WEIGHT LOSS Every Day:Sleep 8 hoursEat breakfastWalk briskly 60 minutesWrite down what you eatWeighFind supportNever give up

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