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

1. Global Experience in Building
Sustainable 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. Increasing prevalence of obesity
worldwide
Between 1980 & 2008, the mean BMI
worldwide increased by 0.4 kg/m² per decade
for men and 0.5 kg/m² for women
In 2008, 1.46 billion adults worldwide were
overweight or obese
Of these, 205 million men (9.8%) and 297
million women (13.8%) were obese
Finucane et al, Lancet, 2011

3. Increasing prevalence of obesity in
USA
If 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

5. Sectors of Society
Science & Arts &
Technology Entertainment
Commerce
Law & Politics & Trade
Healthcare Education
Family/
Community

6. 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."

7. Education
National School Lunch Program

8. Commerce and Trade
Farmers’ Markets

9. Science & Technology
WiiFit
X-box
Kinect
Nike run
Health
Blogs
Phone Apps

10. Arts and Entertainment

11. Family/Community
Walking School
Bus walk to
"Kids used to
school all the time,"
Whatley says. "Now,
it's almost
impossible." And with
childhood obesity
rates on the rise,
Whatley says
walking is important
because it's the
"easiest way to
exercise for a
lifetime."

12. Health Care

13. 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

14. Results of Lifestyle Interventions for
Weight Loss
Weekly group sessions over 4 – 6 months
Mean 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.

15. Results of Lifestyle Interventions:
Pattern of Weight Regain
Weight regain occurs steadily over 2-5 yrs
Long-term follow-ups of behavioral
interventions show a reliable pattern of
gradual regaining of lost weight
Long-term losses of ≥ 5 Kg are sustained in
less than 20% of patients in behavioral
treatment
Perri, Foreyt, & Anton. Preventing Weight
Regain After Weight Loss. 2008.

16. 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.

17. Population-wide prevention of obesity
Small changes in diet and physical activity may make more
sense than focusing on large behavioral changes
By cutting 100 calories a day, adults can prevent weight
gain
Hill et al, Science, 2003; Hill, AJCN, 2009

18. BENEFITS OF MODEST WEIGHT LOSS
“Several studies demonstrate that small losses…help
reduce obesity-related co-morbidities and that
improvements in these risk factors persist with
maintenance 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

19. Stigmatization & Discrimination
Societal beliefs that weight can be
controlled, thereby suggestive of
character 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.

21. DISCRIMINATION:
THE PAIN OF OBESITY
Former 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.

22. Psychosocial Burden of Obesity
Obese individuals often feel
misunderstood, neglected, and rejected
Obese individuals have low employment
prospects, and are denied educational,
vocational, and advancement
opportunities
Significantly poorer quality of life
van Hout GCM., van Oudheusden I., & van Heck GL. Obes. Surg. 2004

30. Building Sustainable Healthy
Communities:
Healthy Lifestyle
A Healthy Lifestyle is All About
Balance:
Healthy Diet
Healthy Physical Activity

31. Building Sustainable Healthy
Communities:
Healthy Lifestyle
UNFORTUNATELY…

33. Big Texan Steak Ranch
Amarillo, Texas
72-oz Steak FREE if eaten within 1 hour

39. AVERAGE ADULT AMERICAN MAN
Height: 5’ 8”
Weight: 195 lbs
Waist: 39.7 in.
BMI: 28.4
CDC, 2011

40. AVERAGE ADULT AMERICAN WOMAN
Height: 5’3”
Weight: 165 lbs
Waist: 37.0 in.
BMI: 26.1
CDC, 201

43. Miss America,
2008
Kirsten Haglund
BMI: 16.29

44. Eliana Ramos
Age: 18
Height: 5’9”

45. 29th OLYMPIAD
BEIJING, CHINA
US wrestling team captain, Daniel
Cormier (211.5 lbs), hospitalized for
kidney failure as result of
dehydration related to cutting weight
(did not compete).
US boxer, Gary Russell was found
unconscious 4 days before his
Olympic bout due to cutting weight
(did not compete).

46. 29th OLYMPIAD
BEIJING, CHINA
Michael Phelps
8 Gold Medals, Swimming
Age: 23
Height: 6’4”
Weight: 195 lbs
BMI: 23.74
Daily Food Intake: 10,375 KCAL
(15% PRO, 58% CHO, 27% FAT)
Exercise: 30 hrs/wk

48. 2005: USDA FOOD PYRAMID
“The food pyramid
is too complicated
and has too many
messages.”
Robert Post, PhD. USDA Deputy
Director, 2011

49. 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

50. 2011: USDA MY PLATE
“We are all
bombarded with so
many dietary
messages that it is
hard to find time to
sort through all this
information.”
Michelle Obama, 2011

51. Dietary Guidelines for Americans
2010: Two Primary Concepts
Maintain calorie balance over time to
achieve and maintain a healthy weight
Focus on consuming nutrient-dense foods
and beverages
Dietary Guidelines for Americans, 2010

52. 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

53. 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

54. 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

55. READINESS TO CHANGE
“Habit is habit, and not to be
flung out of the window, but
coaxed downstairs a step at a
time.”
Mark Twain

56. Long-Term Weight Maintenance
National Weight Control Registry (N=10,000)
Survey of 3,000 members who have been in the
Registry for at least 10 years
Starting weight = 224 lbs; Average weight loss=69
lbs.
At 5 years, participants had maintained an average
weight loss=52 lbs.
At 10 years, participants had maintained an average
weight loss=51 lbs.
Thomas, Bond, Phelan et al., TOS, 2011

57. Long-Term Weight Maintenance
Weight 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

58. Long-Term Weight Maintenance
Weight 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

59. LONG-TERM WEIGHT MAINTENANCE
Continued consumption of a low-
calorie diet with moderate fat intake
Limited fast food
High levels of physical activity
Phalen et al, Obesity 2006; 14: 710-716

60. 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

61. 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.

62. Most Promising Strategies For
Preventing Weight Regain
Extended treatments have shown
promise in promoting adherence to
the behaviors required for the long-
term maintenance of weight loss
Continuous care approach, focused
on reasonable long-term objectives,
appears appropriate for most
patients
Perri, Foreyt, & Anton. Preventing Weight Regain After Weight

63. An Example of a successful long-term
intervention:
The Look AHEAD Study
Does Weight Loss Reduce
Cardiovascular Disease and Death in
Overweight Individuals with Diabetes?

64. 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

65. Look AHEAD
Primary End Point Composite
• Cardiovascular death (including fatal
myocardial infarction and stroke)
• Non-fatal myocardial infarction
• Non-fatal stroke

66. Clinical Sites
Seattle
Boston
Minneapolis Providence
New York
Pittsburgh Philadelphia
Baltimore
Denver
Winston-Salem
Memphis
Phoenix
Los Angeles
Birmingham
Houston
San Antonio
Baton Rouge
Clinical Site Coordinating Center

67. Look AHEAD
Participants
Lifestyle DSE
(N=2630) (N=2574)
Women 59% 60%
Minority 37% 37%
Age (years) 58.6 58.9
Insulin Users 14% 15%
Baseline BMI 35.9 36.0
Baseline weight (kg) 100 101
Attended 1 year exam 96% 94%*
* p < .0004

68. Look AHEAD
Study Interventions
• Diabetes support and education - DSE
(control group)
• Lifestyle intervention – ILI (treatment
group)

69. Look AHEAD
Lifestyle Intervention
Goals:
• 7% weight loss for the group (10%
for individual)
• 175 minutes of moderate intensity
activity

70. 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)

71. Look AHEAD
Lifestyle Intervention
• Physical Activity
– unsupervised
– 175 minutes moderate intensity/week
– 5 days/week
– walking

72. % 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

73. % 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

74. Fitness Change (%) at 1-Year
25 20.9
Mean % 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

75. 1-Year Changes in Markers of
Diabetes Control
Markers of Diabetes
Control ILI DSE P-value
Hemoglobin A1c (%), BL 7.25 7.29 0.26
Hemoglobin A1c (%), Y1 6.61 7.15 <0.001
Y1 – Baseline -0.64 -0.14 <0.001
Fasting glucose (mg/dl), BL 151.9 153.6 0.21
Fasting glucose (mg/dl), Y1 130.4 146.4 <0.001
Y1 – Baseline -21.5 -7.2 <0.001
Diabetes medications, BL 86.5% 86.5% 0.93
Diabetes medications, Y1 78.6% 88.7% <0.001
Y1 – Baseline -7.8% 2.2% <0.001

76. 1-Year Changes in Markers of
Blood Pressure Control
Markers of Blood Pressure
Control ILI DSE P-value
Systolic BP (mmHg), BL 128.2 129.4 0.26
Systolic BP (mmHg), Y1 121.4 126.6 <0.001
Y1 – Baseline -6.8 -2.8 <0.001
Diastolic BP (mmHg), BL 69.9 70.4 0.11
Diastolic BP (mmHg), Y1 67.0 68.6 <0.001
Y1 – Baseline -3.0 -1.8 <0.001
Antihypertensive medications, BL 75.3% 73.7% 0.23
Antihypertensive medications, Y1 75.2% 75.9% 0.54
Y1 – Baseline -0.1% 2.2% 0.02

77. 1-Year Changes in Markers of Lipid
Control
Markers of Lipid Control ILI DSE P-value
LDL-cholesterol (mg/dl), BL 112.2 112.4 0.78
LDL-cholesterol (mg/dl), Y1 107.0 106.7 0.74
Y1 – Baseline -5.2 -5.7 0.49
HDL-cholesterol (mg/dl), BL 43.5 43.6 0.80
HDL-cholesterol (mg/dl), Y1 46.9 44.9 <0.001
Y1 – Baseline 3.4 1.4 <0.001
Triglycerides (mg/dl), BL 182.8 180.0 0.38
Triglycerides (mg/dl), Y1 152.5 165.4 <0.001
Y1 – Baseline -30.3 -14.6 <0.001
Lipid lowering medications, BL 49.4% 48.4% 0.52
Lipid lowering medications, Y1 53.0% 57.8% <0.001
Y1 – Baseline 3.7% 9.4% <0.001

78. 1-Year Changes in Percent of Participants
Meeting ADA Goals
ADA Goal ILI DSE P-value
Hemoglobin A1c < 7%, BL 46.3% 45.4% 0.50
Hemoglobin A1c < 7%, Y1 72.7% 50.8% <0.001
Y1 – Baseline 26.4% 5.4% <0.001
Blood pressure < 130/80 mmHg, BL 53.5% 49.9% 0.01
Blood pressure < 130.80 mmHg, Y1 68.6% 57.0% <0.001
Y1 – Baseline 15.1% 7.0% <0.001
LDL-cholesterol < 100 mg/dl, BL 37.1% 36.9% 0.87
LDL-cholesterol < 100 mg/dl, Y1 43.8% 44.9% 0.45
Y1 – Baseline 6.7% 8.0% 0.34
All three goals, BL 10.8% 9.5% 0.13
All three goals, Y1 23.6% 16.0% <0.001
Y1 – Baseline 12.8% 6.5% <0.001

79. Mean Changes in Weight, Fitness & BP
Averaged Over Four Years
DSE ILI P-value
Mean Mean
Weight Loss -0.88 -6.15 < 0.0001
(% initial wt)
Fitness 1.96 12.74 <0.0001
(% METS)
HbA1c -0.09 -0.36 < 0.0001
SBP (mm Hg) -2.97 -5.33 < 0.0001
DBP (mm Hg) -2.48 -2.92 0.012
Look AHEAD Research Group, Arch Int Med, 2010.

80. Mean Changes in Lipid Profile
Averaged Over Four Years
DSE ILI P-value
Mean Mean
HDL (mg/dl) 1.97 3.67 <0.0001
TG (mg/dl) -19.75 -25.56 0.0006
LDL (mg/dl) -12.84 -11.27 0.009
LDL (mg/dl) -9.22 -8.75 0.42
(Adjusting for
medication use)
Look AHEAD Research Group, Arch Int Med, 2010.

81. Percent (%) Completing Outcome
Measures at Years 1-4
Intervention Group Comparison Group
(ILI) (DSE)
Year 1 97.1 Year 1 95.7
Year 2 94.9 Year 2 93.5
Year 3 94.0 Year 3 93.8
Year 4 94.1 Year 4 93.1

82. Look AHEAD Summary
ILI had significantly greater improvements
than DSE in all CVD risk factors averaged
across 4 years (except LDL-C)
There may be long-term beneficial effects
from this 4-year period in which ILI subjects
have been exposed to lower CVD risk factors
Longer follow-ups will determine whether
these lowered CVD risk factors can be
maintained & whether lifestyle intervention
has positive effects on CVD morbidity &
mortality

83. Mary J.
Female
White
56 years old at start of Look AHEAD
study
Past Medical History: Type 2 diabetes,
overweight, diverticulosis, arthritis,
sleep apnea, back pain

85. 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

86. 8/2007:
grandkids
enter pre-
Pounds
school
Years

87. Catherine L.
Female
White
47 years old at start of Look AHEAD
study
Past Medical History: Type 2 diabetes,
overweight, high blood pressure,
hypothyroidism, back pain

89. 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

90. Pounds
Years

91. Realistic Management Goals
 5-10% weight loss
 Health, energy and fitness
 Well-being and self-esteem
 Mood and appearance
 Functional and recreational
activity

92. Key Elements
Focus on health and energy
Food and physical activity diaries
Gradual increase in physical activity
Gradual reduction in dietary fat
No feelings of food deprivation
Social support groups

93. Recommended Strategies for Building
Sustainable Healthy Communities:
Overview from USA
Promote the availability of affordable healthy
food and beverages
Support healthy food and beverage choices
Encourage breastfeeding
Encourage physical activity or limit sedentary
activity among children & youth
Create safe communities that support physical
activity
Encourage communities to organize for change

94. Recommended Community Strategies
Strategies 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

95. Recommended Community Strategies
Strategies 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

96. Recommended Community Strategies
Strategies 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

97. Recommended Community Strategies
Strategies 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

98. Recommended Community Strategies
Strategies 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

99. Recommended Community Strategies
Strategies 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

100. Recommended Community Strategies
Strategies 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

101. Recommended Community Strategies
Strategies 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

102. Recommended Community Strategies
Strategies 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

103. Recommended Community Strategies
Strategies 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

104. 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

105. Recommended Community Strategies
Strategies 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

106. Recommended Community Strategies
Strategies 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

107. Recommended Community Strategies
Strategies 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

108. Recommended Community Strategies
Strategies 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

109. Recommended Community Strategies
Strategies 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

110. Recommended Community Strategies
Strategies 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

111. Recommended Community Strategies
Strategies 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

112. Recommended Community Strategies
Strategies 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

113. Recommended Community Strategies
Strategies 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

114. Recommended Community Strategies
Strategies 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

115. Geospatial Mapping: Linking Urban
Environments to Health Risk
Measure association between
environmental variables & health
risk factors
Assess relationships between
variables at different levels of
analysis
Used in conjunction with linear
analyses

116. Our Community Environmental Model
of Obesity
Community 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

117. Chosen Neighborhoods
Census-block groups in the metro Kansas
City area (Missouri) were identified based on
a median income split (i.e., low and high
income) and mapped
We then matched census-block groups within
the income groups by population density and
percentage of minority representation
One matched block group per income level
was randomly selected

118. Prevalence of Obesity in
Block-Groups*
*Age-standardized to the 1990 U.S. Census
Age-adjusted Obesity Prevalence (%)
50
45
40
35
30
25
20
15
10
5
0
High-Income Low-Income

119. 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

120. 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

121. Percent Substandard (or worse) Housing
or Ground Conditions
of Residential Properties
30
Percent (%)
20
10
0
Structural Grounds
Low-Income High-Income

124. CONCLUSIONS
These data suggest that the higher
frequency of outlets providing
calorically-dense foods and alcohol may
contribute to greater obesity prevalence
in residents of low-income communities
More research is needed to thoroughly
document environmental determinants
of health and obesity

125. Neighborhoods, Obesity, and Diabetes:
A Randomized Social Experiment
From 1994-1998, HUD randomly assigned
4,498 women with children living in public
housing in high-poverty urban census
tracts to one of three groups: (1) housing
vouchers redeemable only if they moved
to a low-poverty census tract; (2)
unrestricted vouchers; or (3) control group
(no vouchers)
Ludwig et al, NEJM, 2011:365;16

126. Neighborhoods, Obesity, and Diabetes:
A Randomized Social Experiment
10-12 year follow-up showed modest but
potentially important reductions in the
prevalence of extreme obesity & diabetes in the
group moving from a neighborhood with high
poverty on one of low poverty compared to the
control group
No differences between the group receiving
traditional vouchers & the control group
“Neighborhoods matter”
Ludwig et al, NEJM, 2011:365;16

127. Recommended Community Strategies
Strategies 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

128. 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

129. What is the US Government doing?
Community Transformation Grants (CTG) to
States and Communities
$103 million awarded to 61 states and
communities, including state & local government
agencies, tribes & territories, & state & local non-
profit organizations
To build capacity to implement changes for
community prevention efforts to ensure long-
term success
To implement evidence-based and practice-
based programs to improve health & wellness
www.cdc.gov/10/5/2011

130. What is the US Government doing?
Community Transformation Grants (CTG) to
States and Communities
Priority 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

131. What is the US Government doing?
Community Transformation Grants (CTG) to
States and Communities
Applicants proposed specific activities in
line with their chosen priority areas in their
applications
Grantee activities will not be finalized until
plans are negotiated with CDC by early
2012
www.cdc.gov/10/5/2011

132. What is the US Government doing?
Community Transformation Grants (CTG) to
States and Communities
Example 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

133. What is the US Government doing?
Community Transformation Grants (CTG) to
States and Communities
Example 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

134. Building sustainable healthy
communities: Bottom line
Obesity is an environmental problem
Despite progress in genetic research, public health
advances only will occur when we take the
environment seriously
Acknowledging the role of the environment in the
etiology of obesity will help us stop focusing on the
individual, which is encouraged by genetic and
biological explanations, and begin focusing on
changing the toxic environment
Until we do this, we will not make substantial
progress in addressing the epidemic of obesity
Poston & Foreyt, Atherosclerosis, 1999

135. What’s the best approach?
Integrate all sectors of society into community
change interventions
Incorporate: 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

136. Project FIT: rationale, design and baseline characteristics of a school- and community-
based intervention to address physical activity and healthy eating among low-income
elementary 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.
Source
Department of Kinesiology, Michigan State University, East Lansing, MI, USA. jce@msu.edu
Abstract
BACKGROUND:
This paper describes Project FIT, a collaboration between the public school system, local
health systems, physicians, neighborhood associations, businesses, faith-based leaders,
community agencies and university researchers to develop a multi-faceted approach to
promote physical activity and healthy eating toward the general goal of preventing and
reducing childhood obesity among children in Grand Rapids, MI, USA.
METHODS/DESIGN:
There are four overall components to Project FIT: school, community, social marketing, and
school staff wellness - all that focus on: 1) increasing access to safe and affordable physical
activity and nutrition education opportunities in the schools and surrounding neighborhoods; 2)
improving the affordability and availability of nutritious food in the neighborhoods surrounding
the schools; 3) improving the knowledge, self-efficacy, attitudes and behaviors regarding
nutrition and physical activity among school staff, parents and students; 4) impacting the
'culture' of the schools and neighborhoods to incorporate healthful values; and 5) encouraging
dialogue among all community partners to leverage existing programs and introduce new
ones.

137. 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.

138. Building sustainable healthy
communities
“Accuse not nature.
She has done her part.
Do Thou but Thine.”
John Milton (1687), Paradise Lost

139. SECRETS OF SUCCESSFUL WEIGHT LOSS
Every Day:
Sleep 8 hours
Eat breakfast
Walk briskly 60 minutes
Write down what you eat
Weigh
Find support
Never give up