This document provides results from Steps 1-3 of the Evidence-Based Public Health Framework for obesity prevention in Colorado. Step 1 involved assessing the community through analyzing demographics, barriers, community values, and assets. It found the population is growing and aging, with increasing poverty and disparities. Barriers to healthy behaviors include time, money, and access. Health and role modeling are important community values. Assets include outdoor spaces and advocacy groups. Opportunities for obesity prevention include existing partnerships and Colorado's reputation for health.

1. Using the Evidence-Based
Public Health Framework for
Obesity Prevention
Results from Steps 1-3:
(1) Community Assessment
(2) Quantify the Issue
(3) Develop a concise statement of the issue
February 2012

2. Evidence-Based Public Health
Framework
Brownson RC, Gurney JG, Land G. 1999. Evidence-based decision making in
2
public health. J Public Health Manag Pract. 5:86–97.

3. Disclaimer
• Step 1 (Q1–Q3) and Step 2 results include existing Colorado
data only, data limitations and gaps exist in these data. Results
presented do not include results from the research literature
or information from personal experience.
• The results presented are not a fully comprehensive analysis
of all available Colorado data related to obesity, physical
activity, and nutrition. A few additional indicators could be
analyzed, and additional disparities and trends could be
analyzed.
• Step 3 is a summary of data presented here. Because of
limitations and gaps associated with Steps 1–2, there are
limitations to the conclusions drawn in Step 3. I.e., Step 3 is a
summary of what the existing Colorado data tells us.

4. Step 1: Community Assessment
What is it?
• Define the health issue according to the
needs and assets of the
population/community of interest
• Can include:
– Population characteristics, needs, values, and
preferences
– Resources, including practitioner expertise
– Environmental and organizational context
4

5. Step 1: Community Assessment
What is the purpose?
• Provide insight into the community context
• Ensure interventions will be designed and
implemented to maximize benefit to
communities
• Make decisions on where to focus resources
and interventions
• Ensure all partners understand the issues
5

6. Step 1: Community Assessment
What are potential data sources?
• U.S. Census and American Community Survey
• State Demography Office
• Special surveys and survey questions
– E.g., State-added BRFSS and CHS questions
• Focus groups
• Key informant interviews
6

7. Step 1: Community Assessment
What questions were answered?
1. What are the characteristics of our community?
2. What are barriers to physical activity and healthy eating
in our community?
3. What is important to the community?
4. What are the community’s assets?
5. What are the threats to increasing PA and healthy eating?
6. What are the opportunities for increasing PA and healthy
eating?
7. What are the competencies and capacities of the public
health system?
8. What are the current activities of the public health
system?
7

8. Step 1: Community Assessment
Q1. What are the characteristics of our
community?
8

9. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Age
Age Group Total Percent 1% of Total
Children 0-5 years 413,949 8.2 4,139
Children 6-17 years 811,660 16.1 8,116
Adults 18-64 years 3,253,962 64.7 32,539
Adults 65+ years 549,625 10.9 5,496
Data source: CoHID http://www.chd.dphe.state.co.us/cohid/Default.aspx
Median age: 36.1 years (U.S. Census)
9

10. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Race/Ethnicity
Race/Ethnicity Total Percent 1% of Total
Black 188,778 3.8% 1,887
American Indian/Alaska Native 31,244 0.6% 312
Asian/Pacific Islander 141,225 2.8% 1,412
Hispanic or Latino 1,038,687 20.7% 10,386
Two or more races 100,847 2.0% 1,008
White 3,520,793 70.0% 35,207
Other 7,622 0.2% 76
Data source:
http://dola.colorado.gov/dlg/demog/2010data/race%20and%20hispanic%20origin%20s
tate_2000%202010.pdf
10

11. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Trends by Age and Ethnicity
• 2010–2020: Population aged 65–74 years is
forecast to increase 7% per year compared to
the state at 1.8% and the U.S. at 4.1%.
• By 2030: Population aged 65+ years will be
150% larger than in 2010.
– 540,000 to 1.35 million (just from aging)
• 2000–2010: Hispanic population increased 41%
– Total population increased 16.9%.
Source: State Demography Office 11

12. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Education
Demographic Group Total Percent 1% of Total
Ages 18-24 years 492,348
Did not complete high school 75,821 15.4 758
High school 142,288 28.9 1,422
Some college/Associate’s degree 218,110 44.3 2,181
Bachelor’s degree or higher 55,635 11.3 556
Ages 25 years and older 3,328,045
Did not complete high school 346,116 10.4 3,461
High school 758,794 22.8 7,587
Some college/Associate’s degree 1,011,725 30.4 10,117
Bachelor’s degree or higher 1,211,408 36.4 12,114
Data source: http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
12

13. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Poverty
Demographic Group Total Percent 1% of Total
Below federal poverty level – total 659,786 13.4% 6,597
White 479,526 11.6% 4,795
Black or African American 47,299 25.7% 472
American Indian or Alaska Native 12,166 25.9% 121
Asian 13,982 10.6% 139
Native Hawaiian and Other Pacific Islander N/A N/A N/A
Other race 76,624 27.6% 766
Two or more races 28,984 17.5% 289
Below federal poverty level – Ages 25 and older 328,599 10.0% 3,285
Less than high school 82,210 25.3% 822
High school graduate 95,366 12.9% 953
Some college, associate’s degree 95,438 9.5% 954
Bachelor’s degree or higher 55,585 4.6% 555
13
Data source: http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_S1701&prodType=table

14. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Poverty Trends
• Poverty has increased from 2001–2008
– The total poverty rate in Colorado increased from 9.6% in 2001 to
11.4% in 2008.
– Colorado’s child poverty rate increased from 12.2% in 2001 to 15.1%
in 2008.
• [From 2008 to 2009, the number of children living in poverty in Colorado rose
by 31,000, an increase from 15% to 17%.]
– The family poverty rate increased from 6.8% in 2001 to 7.8% in
2008.
– All of the above changes are statistically significant, and place
Colorado 33nd among states in overall poverty and 32nd in child
poverty.
Data sources: http://www.cclponline.org/pubfiles/Colorado%20Poverty%20Factsheet%20FINAL10-14.pdf and
http://www.coloradokids.org/facts/kids_count/ 14

15. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Child Poverty by County
Source: http://www.coloradokids.org/facts/kids_count/ 15

16. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Child Poverty by Race/Ethnicity
Source: http://www.coloradokids.org/facts/kids_count/ 16

17. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Participation in Safety Net
Programs
Source: http://www.coloradokids.org/facts/kids_count/ 17

18. Step 1: Community Assessment
Q1. What are the characteristics of our community?
Colorado Demographics – Miscellaneous
Demographic Group Total Percent 1% of Total
Female 2,508,534 49.9% 25,085
Male 2,520,662 50.1% 25,206
Persons with a disability* 498,680 10.1% 4,986
Ages 18-64 years 272,809 8.5% 2,728
Ages 65+ years 185,219 34.5% 1,852
Lesbian, Gay, or Bisexual** 100,583 2.0% 1,005
Resident of rural county (51 counties 708,075 14.1% 7,080
with <50,000 population)
*Civilian, noninstitutionalized persons with a disability
** Based on 2010 BRFSS estimate of 2.0% and 2010 state population of 5,029,196 (U.S. Census)
Data source: http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_SF1_QTP1&prodType=table
18

19. Step 1: Community Assessment
Q2. What are barriers to physical activity and
healthy eating in our community?
19

20. Step 1: Community Assessment
Q2. Barriers to Physical Activity and Healthy Eating
Time
&
Money
Data source: 2009 Colorado Health Marketing 20
Communications Attitude and Behavior Study

21. Step 1: Community Assessment
Q2. Potential Barriers to Physical Activity
Access Access Access past 30 days
Data source: 2009 BRFSS 21

22. Step 1: Community Assessment
Q2. Barriers to Physical Activity
It is difficult for child to be active because…
Data source: 2010 CHS
22

23. Step 1: Community Assessment
Q2. Potential Barriers to Healthy Eating
• 5.4% Do not have easy access to a grocery
store from their house
• 4.3% Do not have affordable fresh
fruits, vegetables, and other healthful foods
available in their neighborhood
Data source: 2009 BRFSS
23

24. Step 1: Community Assessment
Q3. What is important to the community?
24

25. Step 1: Community Assessment
Q3. What is important to the community?
• Being healthy is important to Coloradans
– 92% say living a long, healthy life is priority
– 91% are currently making efforts to improve
health
– 83% are currently trying to eat healthier
– 80% try to be a role model for family
Data source: 2009 Colorado Health Marketing
Communications Attitude and Behavior Study
25

26. Step 1: Community Assessment
Q3. What is important to the community?
• Reasons Coloradans give to pursue health:
– 86% To feel better physically
– 85% To prevent illness
– 82% To have more energy
– 81% To live longer to be around for family
– 75% To feel better emotionally
– 37% To look more attractive
Data source: 2009 Colorado Health Marketing
Communications Attitude and Behavior Study
26

27. Step 1: Community Assessment
Q3. What is important to the community?
• Stakeholders feel that it is important for
CDPHE to:
– Provide obesity, physical activity, and nutrition
data to stakeholders
– Fill data gaps in obesity, physical activity, and
nutrition data
– Be the liaison between CDC and stakeholders
– Work with other state agencies on physical activity
and healthy eating initiatives
Source: PANO Stakeholders Input Meeting, September 2011 27

28. Step 1: Community Assessment
Q4. What are the community’s assets?
Q5. What are the threats to increasing PA and
healthy eating?
Q6. What are the opportunities for increasing PA
and healthy eating?
Q7. What are the competencies and capacities
of the public health system?
Q8. What are the current activities of the public
health system?
28

29. Step 1: Community Assessment
Q4. What are the community’s assets?
• Access to outdoor recreation and mountains
– 12 National Parks, 42 State Parks
• 22 LiveWell communities
• Community Transformation Grant
• Food Systems Advisory Council
• Healthy Eating and Active Living Coalition
• Grassroots Advocacy Power Program
• Denver B-Cycle
29

30. Step 1: Community Assessment
Q4. What are the community’s assets?
Other general assets:
• Local neighborhood organizations, community centers, seniors' groups
• Local officials, politicians, and leaders
• Local public schools, universities, and community colleges
• Public hospitals or clinics
• Public or private educational institutions
• State or federal agencies
• Municipal libraries
• Police officers and other emergency personnel
• Parks and municipal pools or golf courses
• Housing organizations
• Food kitchens and emergency housing shelters
• Halfway houses, substance abuse homes, domestic violence shelters
• Churches
• Clinics and counseling centers
• Advocacy groups for environment, safety, drug abuse reduction, et cetera
• Banks
• Chamber of commerce
• Businessmen's/businesswomen's associations
• Local businesses
• Special populations: senior citizens, local musicians, local artists, immigrant populations, those
receiving public assistance, food stamps, Medicaid or Medicare, youth, college students

31. Step 1: Community Assessment
Q5. What are the threats to increasing physical activity
and healthy eating?
• Limited funding within CDPHE, potentially reduced
future funding
• Lack of political will, especially for certain policy
efforts
• Limited state public health role for various efforts
• Inherent difficulties with changing individuals’
behaviors
• Colorado is known nationally as a healthy state with
the lowest obesity prevalence
31

32. Step 1: Community Assessment
Q6. What are the opportunities for increasing physical
activity and healthy eating?
• Obesity is currently a priority area for
CDPHE, PSD, and many local health agencies
– Obesity prevention and control strategies will be a part of
the PSD work plan and local health agencies’ work plans as
part of the Public Health Improvement Plans
• Strong partnerships with stakeholders, such as
LiveWell Colorado, Colorado Health Foundation, and
Kaiser Permanente
• Colorado is known nationally as a healthy state with
the lowest obesity prevalence
32

33. Step 1: Community Assessment
Q6. What are the opportunities for increasing physical
activity and healthy eating?
Examples of key partners’ current and recent activities:
• LiveWell Colorado http://about.livewellcolorado.org/sites/default/files/lwc-2010-ann-
report.pdf
– Funding community coalitions
– Policy Blueprints
– School food programs
• Culinary Boot Camp (also funded by CHF)
• School Meal Assessment Program
• Eatwell@school cooking competition
• Go, Slow, Whoa elementary school food education program
– Let’s Move! campaign partnerships
– Social marketing initiatives
– Data collection and analysis of school wellness policy implementation, healthy food access in
low income communities, and active transportation infrastruture (with KP)
• Colorado Health Foundation (CHF)
– Health is Here campaign
– Funds healthy living initiatives, such as Smart Meal
– Food desert programs
• Kaiser Permanente (KP)
– Weigh and Win
– Funds programs and organizations, such as LiveWell Colorado 33

34. Step 1: Community Assessment
Q7. What are the competencies and capacities of the
public health system?
○ Staff with expertise in a variety of related areas:
– Subject-area expertise/knowledge (e.g., nutrition, breastfeeding,
school health)
– Legal/policy work
– City planning
– Epidemiology, planning, and evaluation
× Staff workloads are high, efforts are sometimes
spread thin
× High staff turnover with resulting loss of historical
program knowledge
34

35. Step 1: Community Assessment
Q7. What are the competencies and capacities of the
public health system?
10 Essential Public Health Services http://www.cdc.gov/nphpsp/essentialservices.html
1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care when
otherwise unavailable.
8. Assure competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health
services.
10. Research for new insights and innovative solutions to health problems.
35

36. Step 1: Community Assessment
Q8. What are the current activities of the public
health system?
• Public health improvement plans • FDA menu labeling
(local health agencies) • Smart Meal promotion
• Physical activity portfolio project • Land use planning for local
• Youth intern project agriculture, including school and
• Joint use agreements community gardens
• Built environment and land use • School wellness and healthy
planning eating
• Worksite Wellness • Nutrition portfolio project
• Physical activity in schools and • Sugar Sweetened Beverage
daycare Research Team
• Early Childhood Obesity • Farm to School Task Force
Initiatives
Source: COPrevent.org
Obesity is one of CDPHE’s 10 Winnable Battles.
Obesity is PSD’s top priority.
Early childhood obesity is a 2011-2015 Colorado Maternal and Child Health Priority.
36

37. Step 1: Community Assessment
Data Limitations and Data Gaps
• Data gaps: list of partners’ activities
37

38. Step 2: Quantify the Issue
38

39. Step 2: Quantify the issue
What is it?
• Purpose: To measure and characterize disease
or risk factor frequency in defined populations
• First steps:
– Define the disease or risk factor
– Define the population of interest
– Define the time frame
39

40. Step 2: Quantify the issue
What are the considerations?
• What is the size of the public health problem?
• What are the high-risk groups?
– By person and place
• What are the trends?
• Are the data measuring what we want?
• What are the issues with having multiple ways
to measure the same thing?
• How to incorporate existing priorities?
40

41. Step 2: Quantify the issue
What are potential data sources?
• BRFSS
• CHS
• YRBS
• PRAMS
• Basic Screening Survey (oral health)
• Colorado Central Cancer Registry
• Vital statistics
• Colorado Hospital Association data
• etc.
41

42. Step 2: Quantify the issue
What questions were answered?
Q1. Obesity prevalence, trend, disparities
Q2. Physical activity prevalence, trend, disparities
– Physically inactive
– Moderate/vigorous activity
– Commuting to work
– Physical education class
– Sports
– Screen time
Q3. Nutrition prevalence, trend, disparities
– Fruit/vegetable consumption
– Soda, sweets, and fast food consumption
42

43. Step 2: Quantify the issue
Obesity
Prevalence, Trends, and Disparities

44. Step 2: Quantify the issue
Obesity Definitions
• Adult (ages 18+ years)
– Adult Obesity (BMI≥30.0)
– Adult Overweight (25.0≤BMI<30.0)
• Adolescent (high school students) or Child (ages
2–14 years)
– Adolescent or Child Obesity
(BMI≥95th percentile)
– Adolescent or Child Overweight
(85th percentile≤BMI<95th percentile)
BMI: Body Mass Index 44

45. Step 2: Quantify the issue
Adult Obesity — 2010
Data source: 2010 BRFSS
• The prevalence of adult obesity in 2010 was 21.4%.
• Males had a higher prevalence of overweight or obesity (67.1%) compared
with females (47.5%).
45

46. Step 2: Quantify the issue
Adult Obesity Trend
21.4
17.8
14.2 Significant increase 1995–2010
10.1
Data source: BRFSS
46

47. Step 2: Quantify the issue
Adult Obesity by Age
25.2
12.8
Data source: 2010 BRFSS The prevalence of obesity was higher among
adults aged 55-64 years (25.2%) compared with
adults aged 18-24 years (12.8%). 47

48. Step 2: Quantify the issue
Adult Obesity by Race/Ethnicity
26.5
20.0
Data source: 2010 BRFSS The prevalence of obesity was higher among
Hispanic adults (26.5%) compared with
White, non-Hispanic adults (20.0%). 48

49. Step 2: Quantify the issue
Adult Obesity by Income
No difference by income
30.5 30.6
19.0
Data source: 2010 BRFSS The prevalence of obesity was higher among
adults with household incomes <$15,000 or
$15,000–24,999 (30.5% or 30.6%) compared with
adults with household incomes ≥$50,000 (19.0%). 49

50. Step 2: Quantify the issue
Adult Obesity by Education
26.6
16.2
Data source: 2010 BRFSS The prevalence of obesity was higher among
adults with less than high school education
(26.6%) compared with college graduates (16.2%). 50

51. Step 2: Quantify the issue
Adult Obesity by Health Statistics Regions — 2005–2007
51

52. Step 2: Quantify the issue
Adult Obesity Disparities Summary
• Male 67.1%, female 47.5% (overweight or obese)
• Ages 55-64 years 25.2%, Ages 18-24 years 12.8%
• Hispanic 26.5%, White 20.0%
• Income <$15,000 30.5% or $15,000-24,999
30.6%, ≥$50,000 19.0%
• Education <HS 26.6%, college graduate 16.2%
Data source: 2010 BRFSS
52

53. Step 2: Quantify the issue
Adolescent Overweight/Obesity
• Obesity 7.1% in 2009
– No statistical differences by sex, race, grade
– No significant change since 2005
• Overweight or obese 18.2% in 2009
• White 15.3%
• Hispanic 25.6%
Data source: 2009 YRBS
53

54. Step 2: Quantify the issue
Child (2–14 years) BMI Categories —
2010
Data source: 2010 Child Health Survey 54

55. Step 2: Quantify the issue
Child (2-14 yrs) Obesity Trend
10.0% overweight
Data source: CHS No significant change 2004–2010
55

56. Step 2: Quantify the issue
Child (2-14 yrs) Obesity by Age
56
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

57. Step 2: Quantify the issue
Child (2-14 yrs) Obesity by Race/Ethnicity
57
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

58. Step 2: Quantify the issue
Child/Parent Obesity Association
• Children were almost 4 times more likely to be
overweight/obese if their parent was obese
(2010 CHS)
58

59. Step 2: Quantify the issue
Physical Activity
Prevalence, Trends, and Disparities

60. Step 2: Quantify the issue
Physical Activity Definitions
• Physically inactive
– “No” response to: During the past month, other than your regular job,
did you participate in any physical activities or exercises such as running,
calisthenics, golf, gardening, or walking for exercise?
• Moderate/vigorous activity
– Does not get 30+ minutes of moderate PA five or more days/week, or
vigorous PA for 20+ minutes three or more days/week
• Commuting to work
– Commuting refers to a worker’s travel from home to work. Place of work
refers to the geographic location of the worker’s job.
• No sports team (adolescents only)
– Response of 0 to the question: During the past 12 months, on how many sports
teams did you play? (Include any teams run by your school or community
groups.) 60

61. Step 2: Quantify the issue
Physical Activity Definitions
• Physical education class
– Question asked of adolescents: In an average week when you are in school, on how many
days do you go to physical education (PE) classes?
– Question asked of child’s parent: How many times per week does *CHILD’S NAME+ currently
attend physical education class?
• TV Screen time
– Question asked of adolescents: On an average school day, how many hours do you watch TV?
– 2 question asked of child’s parent: On an average *weekday/weekend day+, how much time
does (child’s name) watch TV or DVDs? Do not include time spent watching TV shows or
videos on a computer or playing video games.
• Computer and video game screen time
– Question asked of adolescents: On an average school day, how many hours do you play video
or computer games or use a computer for something that is not school work? (Include
activities such as Nintendo, Game Boy, PlayStation, Xbox, computer games, and the Internet.)
– 2 questions asked of child’s parent: On an average *weekday/weekend day+, how much time
does (child’s name) use a computer for something other than school work or play video or
computer games? Include activities such as Game Boy, PlayStation, Xbox, computer games,
and the Internet. 61

62. Step 2: Quantify the issue
Physically Inactive Adults – Trend
*Does not include
work-related
activity
No significant change 1996–2010
20.2
18.2
Data source: BRFSS
62

63. Step 2: Quantify the issue
Adult Physical Inactivity by Health Statistics Regions —
2005–2007
Counties in the Eastern Plains, particularly the southeastern region, had the highest
prevalence of physical inactivity. Boulder and Douglas Counties had the lowest
adult physical inactivity prevalence. 63

64. Step 2: Quantify the issue
Adult Physical Activity by Quality of Life Measures
Full report available at:
http://www.chd.dphe.state.co.us/Resources/pubs/physicalactivity.pdf
64

65. Step 2: Quantify the issue
Adult Moderate/Vigorous Physical Activity* – Trend
* Does not get 30+ minutes of moderate PA five or more
days/week, or vigorous PA for 20+ minutes three or more
days/week
46.8 42.9
No significant change 2001–2009
Data source: BRFSS
65

66. Step 2: Quantify the issue
Adult Physical Activity* Disparities
* Does not get 30+ minutes of moderate PA five or more days/week,
or vigorous PA for 20+ minutes three or more days/week
• Female 45.1%, male 40.8%
• Age 55-64 years 46.8% and 65+ years 53.3%,
Age 18-24 years 34.9%
• Hispanic 48.9%, White 40.9%
• Income <$15k 49.1%, $50k+ 38.8%
• Education <HS 54.4% and HS 47.0%, college
graduate 37.4%
Data source: 2010 BRFSS
66

67. Step 2: Quantify the issue
Commuting to Work
% of workers
aged 16+ years
Drove alone (car/truck/van) 75.5
Carpooled (car/truck/van) 10.0
Public transportation 3.0
Walked 3.0
Bicycle 1.1
Taxi, motorcycle, other 1.0
Worked at home 6.4
Data source: 2010 American Community Survey
67

68. Step 2: Quantify the issue
Adolescent Physical Activity
Total Male Female 9th 12th White Hispanic
Grade Grade
PA 60+min on <5days 53.0 44.9 61.6 50.0 61.3
PA 60+min on <7days 73.1 67.9 79.6
No PE 55.0 41.1 62.6
No daily PE 79.3
No sports team 36.1
TV 3+hrs/day 25.1 23.3 13.2 20.0 34.9
Computer 3+hrs/day 18.4 29.7 20.5
Data source: 2009 YRBS * Only significantly different prevalence estimates are
reported by sex, grade, and race/ethnicity.
“PA 60+min on <7 days” improved since 2005, when the prevalence was 83.5%.
No change since 2005 was found for other variables; computer time was not assessed in 2005.
68

69. Step 2: Quantify the issue
Child Physical Activity/Inactivity
% No physical activity %
or sports in past
PA <7hrs/week 62.0 week at…
No PE 12.7 School grounds 56.1
No daily PE 80.0 Park or playground 31.0
No daily walk to 79.1 Recreation center 68.7
school
Street or alley 43.7
TV 2+hrs/day 34.1 weekday
70.9 weekend
Computer 2+hrs/day 11.0 weekday
10.9 weekend
Data source: 2010 CHS 69

70. Step 2: Quantify the issue
Child Screen Time Trend
70
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

71. Step 2: Quantify the issue
Child Screen Time by Age
71
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

72. Step 2: Quantify the issue
Child Screen Time by Sex
72
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

73. Step 2: Quantify the issue
Child Screen Time by Race/Ethnicity
73
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

74. Step 2: Quantify the issue
Example of School Policy
• 2011 Bill HB11-1069
• Physical Activity Expectation In Schools
• SIGNED BY GOVERNOR 4/20/2011
The bill directs each school district board of education and the state charter school institute to adopt a
policy that incorporates a minimum number of minutes of physical activity each week into each
elementary school student's schedule. Each school district and the state charter school institute must
report to the department of education (department) specified information concerning the incorporation
of physical activity into the school day, including during before- and after-school programming. The
department must post the information on its web site, correlated with academic information through each
school's school performance report.
74

75. Step 2: Quantify the issue
Healthy Eating and Breastfeeding
Prevalence, Trends, and Disparities

76. Step 2: Quantify the issue
Healthy Eating Definitions
• Fruit/vegetable consumption (adult, adolescent, and child)
– Consumed 100% fruit juices, fruit, green salad, potatoes [excluding
French fries, fried potatoes, or potato chips], carrots, or other vegetables
less than 5 times during the 7 days before the survey
• Sugary drink consumption
– Question asked of adolescents: During the past 7 days, how many times
did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi,
or Sprite? (Do not include diet soda or diet pop.)
– Question asked of adults and child’s parent: On a typical day, how many
glasses or cans of regular soda pop or other sweetened drinks, such as
fruit punch or sports drinks *do you/does (child’s name)+ drink? Do NOT
count diet drinks.
76

77. Step 2: Quantify the issue
Healthy Eating Definitions
• Consumption of sweets
– Question asked of child’s parent: On a typical day, how many servings of
sweets, such as cookies, candy, doughnuts, pastries, cake or popsicles
does (child’s name) have?
• Fast food consumption
– Question asked of adults and child’s parent: Now think about the past
WEEK. In the past 7 days, how many times did [you/(he/she)] eat fast
food? Include fast food meals eaten at school or at home, or at fast food
restaurants, carryout or drive thru.
• Food insecurity
– Question asked of child’s parent (food insecurity=response of “Often
true” or “Sometimes true”: You relied on only a few kinds of low-cost
food to feed (child’s name) because you were running out of money to
buy food. 77

78. Step 2: Quantify the issue
Adult Fruit/Vegetable Consumption – Trend
73.8 75.2
No significant change 1996-2009
Data source: BRFSS
78

79. Step 2: Quantify the issue
Adult Fruit/Vegetable Consumption* Disparities
* Consume fruit and vegetables less than 5 times per day
• Male 80.0%, female 70.5%
• Age 18-24 years 78.3%, 65+ years 69.9%
• Hispanic 80.9%, White 73.9%
• No difference by income
• Education <HS 81.0%, college grad 70.4%
Data source: 2010 BRFSS
79

80. Step 2: Quantify the issue
Adult Fruit/Vegetable Consumption* by BMI
* Consume fruit and vegetables less than 5 times per day
80
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

81. Step 2: Quantify the issue
Adolescent Fruit/Vegetable & Soda Consumption
%
Fruit/Vegetables <5 times/day 75.6
Fruit <2 times/day 66.8
Vegetables <3 times/day 83.8
Soda 1+ time/day 24.6
Data source: 2009 YRBS
• No statistical differences by sex, race, grade
• No significant change in fruit/vegetable
consumption since 2005. (Sugary drink
consumption was not included in 2005 survey.) 81

82. Step 2: Quantify the issue
Child Fruit/Vegetable & Soda Consumption
%
Fruit and vegetables <5 times/day 81.3
< 2 fruit or <3 vegetables per day 90.3
Fruit <2 times/day 51.0
Vegetables <3 times/day 88.6
Sugary drinks 1+ time/day 16.2
Sweets 1+ time/day 69.0
Fast food 1+ time/wk 63.3 Adult prevalence of
fast food consumption
Food insecurity 25.3 1+ time/wk: 64.4%
Data source: 2010 CHS (2009 BRFSS)
82

83. Step 2: Quantify the issue
Child Fruit/Vegetable & Fast Food Consumption Trends
83
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

84. Step 2: Quantify the issue
Child Fruit/Vegetable & Fast Food Consumption by Age
84
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

85. Step 2: Quantify the issue
Child Fruit/Vegetable & Fast Food Consumption by
Race/Ethnicity
85
www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

86. Step 2: Quantify the issue
Example of School Policy
• 2004 Bill SB04-103
• Concerning Policies to Increase the Inclusion of Nutritious Choices in School Vending Machines
• Summary: Directs each school district board of education to adopt a policy by July 1, 2004 that requires,
by the 2006-07 school year, at least 50% of items offered in school vending machines to be healthful foods
or beverages. Prohibits, as of January 1, 2005, school districts from entering into or renewing contracts
that provide for the sale of nonhealthful foods or beverages from school vending machines. Permits the
Department of Education to withhold school district’s equalization dollars at an amount equal to the
estimated district’s profits from the sale of nonhealthful foods or beverages originating from school
vending machines and that withheld dollars be used to assist school districts in providing school breakfast
programs in low-performing schools.
86

87. Step 2: Quantify the issue
Breastfeeding
%
Initiated breastfeeding 88.7
Breastfeeding at 6 months 57.7
Breastfeeding at 12 months 29.3
Breastfeeding exclusively at 46.8
3 months
Breastfeeding exclusively at 22.5
6 months
Data source: 2009 National Immunization Survey (2007 births)
87

88. Step 2: Quantify the issue
Breastfeeding at 6 months — Trend
Percent of Colorado mothers who breastfeed their infants
at 6 months of age, 2004–2010
Percent
Source: Colorado Child Health Survey, Colorado Department of Public Health and Environment
This is not a statistically significant increase from 2004 to 2010.
88

89. Step 2: Quantify the issue
Breastfeeding Disparities
• The disparity in breastfeeding rates between higher-income women and
women of minority and lower-income populations is well-documented,
with lower rates found among lower-income women. As a consequence,
these women and their infants are at increased risk for precisely the
diseases and illnesses that breastfeeding protects against.
• In Colorado, only 39 percent of Latinas are breastfeeding their infants at 6
months of age while 58 percent of white women are breastfeeding at 6
months. (National Immunization Survey)
• A total of 31 percent of white, 29 percent of Hispanic and 25 percent of
African-American women participating in the Colorado WIC program
(income at or below 185 percent of the federal poverty level) are
breastfeeding their infants at 6 months of age.
Reference: Obesity: Breastfeeding, available at
http://www.cdphe.state.co.us/hs/winnableBattles/obesity.html
89

90. Step 2: Quantify the issue
Data Limitations
• Step 2 includes all self-reported data. Child Health Survey data are
reported by the parent for the child. These data are subject to biases,
including recall bias.
• Physical activity
– Only leisure time physical activity is included for adults; data on active
transportation and work-related physical activity are not included; cannot
accurately compare data to current physical activity recommendations
• Healthy eating
– Fruit and vegetable consumption is measured in times/day rather than
servings/day; cannot accurately compare data to current recommendations
• Disparities
– Analysis of disparities is limited by small sample sizes for sub-populations (e.g.,
Black race, rural counties); standard errors of prevalence estimates are often
too large to effectively make comparisons across sub-populations.
• Trends
– Trend data availability varies by indicator; short-term changes in trends might
not be evident or expected. 90

91. Step 2: Quantify the issue
Data Gaps
• Full assessment of disparities across physical activity and healthy eating
• Data on related factors (e.g., high blood pressure, diabetes, injuries)
• Worksite wellness data
• Physical activity data gaps
– Data on active transportation and work-related physical activity to get the full
picture of an adult’s physical activity level
– Objectively measured data on availability, safety, and continuity and
connectivity of sidewalks and trails; availability and cost of facilities and
programs for physical activity
– Perceptions of sidewalk, trail, and park safety; sidewalk and trail continuity
and connectivity
• Healthy eating data gaps
– Additional data on dietary intake to get the full picture of an adult’s eating
pattern
– Data on options for healthy foods other than grocery stores (e.g., farmers’
markets, community gardens, food banks)
– Objectively measured data on availability of affordable healthy food options 91

92. Step 3: Develop a concise
statement of the issue

93. Step 3: Develop a concise statement
of the issue
What is it?
• Purpose: To build support for the issue with
an organization, policy makers, or a funding
agency
• Describes the mission, internal strengths and
weaknesses, external opportunities and
threats, and vision for the future
• Often helpful to describe gaps between the
current status of a program or organization
and the desired goals. 93

94. Step 3: Develop a concise statement
of the issue
What are the considerations?
Include in the issue statement:
– Health condition or risk factor considered
– Population affected
– Size and scope of the problem
– Prevention opportunities
– Potential stakeholders
94

95. Step 3: Concise statement of the issue
• The state health department has been charged by the governor
with developing and implementing prevention and control
strategies to reduce the obesity prevalence in Colorado.
• Obesity has been identified as a CDPHE Winnable Battle and is a
priority for the Prevention Services Division at CDPHE.
• Six local public health agencies have identified obesity as a
Winnable Battle and priority issue as part of their CHAPS
planning process. Additional agencies could follow suit.

96. Step 3: Concise statement of the issue
•The prevalence of obesity in Colorado is increasing, particularly
among adults, and the state’s population is aging. Over the same
period the prevalence of physical activity and fruit & vegetable
consumption have been stable among adults.
•However, the majority of adults, adolescents, and children do not
meet the recommended levels for weekly physical activity or daily
fruit and vegetable consumption. Too many Coloradans eat and
drink high-caloric, low-nutrient, and processed food too often.
•Older adults are less active than younger adults, but they eat
fruits and vegetables more often.
•The Hispanic population is increasing, and its members have a
higher prevalence of obesity, lower levels of physical activity, and
lower fruit & vegetable consumption than Whites.
•Females and adults with low income or low education are less
active than their counterparts.

97. Step 3: Concise statement of the issue
• Few (1/14) adult workers use active means to commute
to work.
• Only 1/5 adolescents and children have daily PE class.
• Many children exceed recommendations for screen time.
• The majority of children eat fast food weekly.
• Breastfeeding exclusivity at 6 months was below the HP2020
target.
• Perceived barriers to healthy living include lack of time and
money more than lack of access to healthy food or facilities
for physical activity.
• About 1/5 parents report that it is difficult for their child to
be active in the local park because it lacks adequate space or
equipment.

98. Step 3: Concise statement of the issue
• Programmatic Issues:
The public health challenge of obesity is underfunded.
Obesity results from a complex interplay of various, individual,
social, economic, and environmental pressures and incentives.
Until now, there has not been a coordinated response to the
problem that reaches across state and local government, the
nonprofit community, and the private sector.
• Future vision:
PSD Programs and Services will use evidence-based strategies
in targeted ways to efficiently and effectively address the
obesity epidemic in Colorado. PSD Programs and Services will
collaborate and coordinate with partners to implement a
multi-faceted approach to the obesity problem, which
facilitates addressing the socio-ecological root causes.