1. Catalyzing Communities to Prevent Obesity:
A Systems Approach
Christina Economos, PhD
Associate Professor
New Balance Chair in Childhood Nutrition
Director, ChildObesity180
October 10, 2013

2. How do you spark social change?
•
Learn from other movements (tobacco, recycling, seat belts, breastfeeding)
•
Call for a Crisis
•
Build on a sound scientific base
•
Nurture spark plugs
•
Recognize the importance of economics
•
Develop coalitions and advocacy
•
Use government strategically
•
Employ mass communication
•
Create environmental and policy changes
•
Develop a clear plan
Economos, C, Brownson, S, DeAngelis, M, Foerster, S, Tucker Foreman, C, Kumanyika, S, Pate R.
What Lessons Have Been Learned From Other Attempts To Guide Social Change? Nutrition Reviews 2001; 59(3):40-56

3. Shape Up Somerville:
Eat Smart. Play Hard.
• A community-based, participatory, environmental
approach to prevent childhood obesity (2002-2005)
• A 3 year controlled trial to study 1st – 3rd grade culturally
and ethnically diverse children and their parents from 3
cities outside Boston
• Goals:
– To examine the effectiveness of the model on the
prevention of undesirable weight gain in children
– Transform a community and inform social change at
the national level
R06/CCR121519-01 from the Centers for Disease Control and Prevention.
Additional support by Blue Cross Blue Shield of Massachusetts, United Way of Mass Bay, The US Potato Board, Stonyfield Farm, and Dole

4. E a rly M o rn in g
E n v iro n m en t
D u r in g S c h o o l
E n v ir o n m e n t
A t H om e
B efore S ch ool P rogram
Home:
Parent, Child, Family
S afe R outes to S ch ool M ap s
 W alking to S chool (-30 k cals)
H ealth ier H om e B reakfast
 Fiber,  S ugar,  F at
A p p rop riate P ortion Sizes
H ealth ier Sch ool B reakfast
 Fiber,  S ugar,  F at
A ppropriate P ortion Sizes
In creased F resh F ru its
B reakfast C oordin ator (~25 kcals)
School:
Child, teachers, administration, staff
P h ysical A ctivity E q u ip m en t for R ecess

P hysical A ctivity (- 25 kcals) 5 days/w k (10 m in)
N utrition & P hysical A ctivity E ducation 1 day/w k
(30 m in)
P hysical A ctivity (- 25 k cals)
H ealth ier S ch ool L u n ch
Fiber,
S ugar,
F at
Increased Fresh Fruits & V egetables
A ppropriate P ortion Sizes
Im proved P resentation and A tm osphere
S ocial M arketing in C afeteria
A lternative “H ealthier” A L a C arte Item s
N ew F ood S ervice E quipm ent
School:
Child, teachers, administration, staff
A fte r n o o n
E n v ir o n m e n t
A t h om e
S afe R ou tes to S ch ool M ap s
 W alking H om e (-30 k cals)
H ealth y H o m e S n ack
 F iber,  S ugar,  F at
School:
Child, teachers, administration, staff
P rofession al D evelop m en t
H ealth ier F u n d raisin g A ltern atives
T eachers
A dm inistrators
F ood S ervice Staff
P E T eachers
A fter S ch ool P rogram
C u rricu lu m :
C ook in g L esson s
P h ysical A ctivity (-30 k cals)
N u trition E d u cation
P rofession al D evelop m en t
Home:
Parent, Child, Family
R e in f o r c in g
E n v ir o n m e n t s
C lassroom M icro U n its
Community:
After school programs
H om e E n viron m en t (~ 15 k cal)
P a ren t N ew sletter w / co u p on s
G row th R ep orts
 S creen T im e
P ro m otion al G ifts
Home:
Parent, Child, Family
Community: Ethnic groups
C om m u n ity E n viron m en t
C om m u n ity “C h am p ion s”
R estau ran t P articip ation
P ed iatrician T rain in g & S u p p ort
C om m u n ity T V A p p earan ces
E th n ic G rou p O u trea ch
C om m u n ity P A R esou rce G u id e
C om m u n ity E ven ts
Health Care System
Community: Restaurants
Local Government
Media

5. RESULTS: BMI z-score at 4 time points
Year 1 Change
Year 1 Change
Intervention vs. Control 1 + 2
Estimate -0.1005
BMI
z-score
Intervention vs.
Control 1 + 2
Estimate -0.1005
P = 0.0011
N = 1178
P = 0.0011
Obesity
2007;15:1325-1336
N = 1178
2 Year Change
Intervention vs.
Control 1 + 2
Estimate -0.0573
P = 0.0054
N = 1028
Fall
2003
Spring
2004
Fall
2004
Spring
2005
Prev Med
2013 Oct;57(4):322-7
N = 922

6. RESULTS: 2 Year behavior Change
Table 2-Adjusted differences in behaviors between intervention and combined control communities after 2-year
intervention period
Baseline
Behavior
Control
Group
After Intervention
Intervention
Group
Control
Group
Intervention
Group
Pre–Post Change:
1
Adjusted Difference
Model Properties
additional covariates
R2
0.09
parental foreign born status, # siblings
0.18
-2.00
(-3.76,-.25)
0.04
# rules
0.21
4.0
(2.9)
0.20
(0.06,0.33)
0.02
87
3.9
(4.2)
0.65
(-0.53,1.82)
0.14
parent marital status, maternal BMI
0.20
2.2
(1.0)
104
1.7
(1.2)
-0.24
(-0.51,0.04)
0.06
# rules
0.27
332
3.9
(1.9)
106
3.0
(2.2)
-0.24
(0.42,0.06)
0.03
parent marital status, # siblings, #
rules
0.22
29.4%
250
54.8%
85
31.8%
0.39
( 0.11,0.89)
0.13
child weight category, # siblings,
maternal BMI
--4
73.6%
337
62.0%
110
71.8%
OR 0.94
(0.88, 1.00)
0.06
n
Mean
(SD)
n
Mean
(SD)
n
Mean
(SD)
n
Mean
(SD)
Effect
(95% CI)
p-value
Fruit &
vegetable
(servings/day)
317
3.1
(1.5)
103
3.5
(1.6)
317
3.4
(1.6)
103
3.7
(1.8)
0.16
(-06,0.38)
Sugarsweetened
beverages
(ounces/day)
265
6.5
(6.0)
72
6.1
(6.3)
265
7.6
(7.0)
72
5.5
(6.7)
Sports (# per
year)
343
2.9
(2.8)
111
3.6
(2.9)
343
3.4
(2.7)
111
Walk to/from
school (# trips
per week)
248
2.7
(4.0)
87
3.5
(4.1)
248
2.6
(3.9)
TV time
(hrs/day)
325
2.2
(1.1)
104
1.6
(1.1)
325
Total screen
time (hrs/day)
332
3.8
(1.8)
106
2.7
(1.6)
TV in
bedroom2 (%
yes)
250
50.4%
85
Dinner with
TV3 (% not
very
much/never)
337
61.4%
110
0.21
Folta S, Kuder J, Goldberg J, Hyatt R, Must A, Naumova E, Nelson M, Economos C. Changes in diet and physical
activity resulting from the shape up Somerville community intervention BMC Pediatrics.2013, 13:157.
--4

7. Using a Systems-Oriented Approach
• Developing an understanding of the whole system is a critical
first step in tackling the problem more effectively
• A systems perspective recognizes that a
complex, reciprocal, interdependent, and interactive
relationship exists between individuals and their environment
• The complex, multifaceted etiology of obesity necessitates
comprehensive systematic approaches to obesity prevention
• Highlights the importance of the circumstances in which an
event occurs (the context), in order to understand the
potential implementation and impact
• Maps out the processes and mechanisms that are needed to
change and alter the social relations that are damaging to
health

8. The Dynamics of Community Change:
The Shape Up Somerville Experience
• To describe the key aspects and dynamics of social
change within the community of Somerville over 10 years
• Retrospective examination of the SUS model using a
systems perspective in an effort to create a framework
that may help guide future community-based childhood
obesity prevention interventions
– qualitative systems analysis informed by individual and
group interviews with key SUS stakeholders and researchers
• To illustrate through the integration of the socioecological model (determinants) and community-based
participatory research methods (approach) by visualizing
the process using a systems perspective (process).

10. Mission
Goal
Catalyst and drive the necessary
systemic changes to reverse the
trend of childhood obesity within one
generation’s time
Improve children’s energy balance
by 150 calories per day
Approach
•
Engage high-level leadership across sectors, using the best
evidence, to design and implement large scale initiatives
•
Blend the rigor of science with the urgency and innovation
of business to spur lasting change at a national level

11. Diverse and impactful initiatives
Key Criteria

Evidence
Base

Scale

Equity

Impact

Feasibility
Healthy Kids Out of
School
Healthy School
Breakfast
Active Schools
Acceleration Project
Implement
nutrition and
physical activity
principles
Evaluate impact
of breakfast in the
classroom
Increase quality
physical activity
in schools
MultiSectoral
Contribution


Time to
Results
Restaurant Initiative
Reduce excess
calories
consumed in
restaurants
ChildObesity180 helps to improve a child’s energy balance by 150 calories per day
Systems modeling – ROI (cost effectiveness) – Collective Impact: confirms direction

12. Accelerating the Movement
Increase quality physical activity
in schools as a means to combat
childhood obesity and evoke the
beneficial health, behavioral, and
academic outcomes that follow.

13. 4-Phase Approach:
> identify
> replicate
> scale
> sustain
(we are here)

14. Physical
Activity
Innovation
Competition

15. > UNCOVER the very
best approaches to
school-time physical
activity
 CELEBRATE &
REWARD champions
for the cause from
around the country
 Partnered with

16. Where do you find innovation?
Fresh Approaches to All School Activity
Students at Red Hawk Elementary participate
in an all-school movement break.

17. Where do you find innovation?
In the Classroom
Student at PS 102 in East Harlem demonstrate
a Just Move classroom break.

18. Where do you find innovation?
Before School
Students from Simon Elementary, Ward 8, Washington
DC enjoying the BOKS program before the bell.

19. Where do you find innovation?
Fresh Challenges
Kids in Corona, CA accept the challenge to run or walk
100 miles over the school year in the 100 Mile Club.

20. Where do you find innovation?
Inspired Champions
Mom Apryl Krakovsky leads Overland Elementary
students through a daily 15 min. morning energizer.

21. Campaign Outcomes
> 23K unique visitors
> 2063 schools registered
> 1203
completed, submitted
applications
> 6500 new champions
added to ASAP network
 1002 grant recipients
named in all 50 states
 - $1000 each = $1 million
Program Mix
700
600
500
400
300
200
100
0

22. Campaign Outcomes
> 23K unique visitors
Champion Mix
> 2063 schools registered500
> 1203
completed, submitted
applications
> 6500 new champions
added to ASAP network
> 1002 grant recipients
named in all 50 states
400
300
200
100
0

23. Evaluating Impact
OBJECTIVE:
Gain understanding of PE/PA
environment before / after ASAP program
implementation
STUDY DESIGN:
• Survey among all 1000 ASAP schools: baseline,
mid-course, year-end
• Physical Activity questions related to:
• Support / Policy
• Opportunities / # minutes/day
• PE teacher professional development
• Implementation of ASAP program
• Student fitness assessment

24. Evaluating Impact
OBJECTIVE:
• Evaluate impact 100 Mile Club & Just Move have
on school-time & daily MVPA
STUDY DESIGN:
• 6 100 Mile Club, 6 Just Move & 6 control schools
• 20-40 students/school (grades 3-5)
• Two evaluation periods: Fall ‘13 & Spring ’14
• Height/Weight
• Accelerometry (7 days)
• MCAS scores (May ‘13 & May ‘14)

25. What’s Next?
Create 10X impact
From 1,000 to 10,000 schools
www.childobesity180.org