Christina Economos, PhDAssociate Professor

New Balance Chair in Childhood NutritionDirector, ChildObesity180

October 10, 2013

Catalyzing Communities to Prevent Obesity:

A Systems Approach

• 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

How do you spark social change?

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

• 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

Shape Up Somerville: Eat Smart. Play Hard.

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 Foods

Early MorningEnvironment

During School Environment

Afternoon Environment

At HomeSafe Routes to School Maps

Walking to School (-30 kcals)Healthier Home Breakfast

Fiber, Sugar, FatAppropriate Portion Sizes

Before School ProgramHealthier School Breakfast

Fiber, Sugar, FatAppropriate Portion SizesIncreased Fresh Fruits Breakfast Coordinator

Reinforcing Environments

Home Environment (~15 kcal)Parent Newsletter w/ couponsGrowth Reports Screen TimePromotional Gifts

Community EnvironmentCommunity “Champions”Restaurant ParticipationPediatrician Training & SupportCommunity TV AppearancesEthnic Group OutreachCommunity PA Resource GuideCommunity Events

At homeSafe Routes to School Maps Walking Home (-30 kcals)Healthy Home Snack Fiber, Sugar, Fat

After School ProgramCurriculum:

Cooking LessonsPhysical Activity (-30 kcals)Nutrition EducationProfessional Development

Classroom Micro UnitsPhysical Activity (- 25 kcals) 5 days/wk (10 min)Nutrition & Physical Activity Education 1 day/wk (30 min)

Healthier Fundraising Alternatives

Professional DevelopmentTeachersAdministratorsFood Service StaffPE Teachers

Physical Activity Equipment for Recess Physical Activity (- 25 kcals)

Healthier School LunchFiber, Sugar, Fat

Increased Fresh Fruits & VegetablesAppropriate Portion SizesImproved Presentation and AtmosphereSocial Marketing in CafeteriaAlternative “Healthier” A La Carte ItemsNew Food Service Equipment

(~25 kcals)

Home:Parent, Child, Family

Home:Parent, Child, Family

Home:Parent, Child, Family

School:Child, teachers, administration, staff

School:Child, teachers, administration, staff

School:Child, teachers, administration, staff

Community:After school programs

Community: Ethnic groups

Local Government

Health Care System

Community: RestaurantsMedia

RESULTS: BMI z-score at 4 time points

N = 922

Year 1 Change

Intervention vs. Control 1 + 2

Estimate -0.1005

P = 0.0011

N = 1178

Fall 2004

Spring 2005

Fall 2003

Spring 2004

BMI z-score

Year 1 Change

Intervention vs. Control 1 + 2

Estimate -0.1005

P = 0.0011N = 1178

Obesity 2007;15:1325-

1336

2 Year Change

Intervention vs. Control 1 + 2

Estimate -0.0573

P = 0.0054N = 1028

Prev Med 2013

Oct;57(4):322-7

Table 2-Adjusted differences in behaviors between intervention and combined control communities after 2-year intervention period Baseline After Intervention

Pre–Post Change: Adjusted Difference1

Model Properties Behavior Control

Group Intervention

Group Control Group

Intervention Group

n

Mean (SD)

n Mean (SD)

n Mean (SD)

n Mean (SD)

Effect (95% CI)

p-value additional covariates

R2

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)

0.09 parental foreign born status, # siblings 0.18

Sugar-sweetened beverages (ounces/day)

265 6.5

(6.0) 72

6.1 (6.3)

265 7.6

(7.0) 72

5.5 (6.7)

-2.00 (-3.76,-.25)

0.04 # rules 0.21

Sports (# per year)

343 2.9

(2.8) 111

3.6 (2.9)

343 3.4

(2.7) 111

4.0 (2.9)

0.20 (0.06,0.33)

0.02 0.21

Walk to/from school (# trips per week)

248 2.7

(4.0) 87

3.5 (4.1)

248 2.6

(3.9) 87

3.9 (4.2)

0.65 (-0.53,1.82)

0.14 parent marital status, maternal BMI 0.20

TV time (hrs/day)

325 2.2

(1.1) 104

1.6 (1.1)

325 2.2

(1.0) 104

1.7 (1.2)

-0.24 (-0.51,0.04)

0.06 # rules 0.27

Total screen time (hrs/day)

332 3.8

(1.8) 106

2.7 (1.6)

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

TV in bedroom2 (% yes)

250 50.4% 85 29.4% 250 54.8% 85 31.8% 0.39

( 0.11,0.89) 0.13

child weight category, # siblings, maternal BMI

--4

Dinner with TV3 (% not very much/never)

337 61.4% 110 73.6% 337 62.0% 110 71.8% OR 0.94

(0.88, 1.00) 0.06

--4

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.

RESULTS: 2 Year behavior Change

• 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

Using a Systems-Oriented Approach

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 socio-ecological model (determinants) and community-based participatory research methods (approach) by visualizing the process using a systems perspective (process).

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

Mission Goal

• 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

Approach

Diverse and impactful initiatives

Healthy Kids Out of School

Restaurant Initiative

Healthy School Breakfast

Active Schools Acceleration

Project

Implement nutrition and

physical activity

principles

Increase quality physical

activity in schools

Reduce excess calories

consumed in restaurants

Evaluate impact of

breakfast in the classroom

Key Criteria

Evidence Base

Scale Equity Impact Feasibility

Multi-Sectoral

Contribution

Time to Results

ChildObesity180 helps to improve a child’s energy balance by 150 calories per day

Systems modeling – ROI (cost effectiveness) – Collective Impact: confirms direction

Accelerating the MovementIncrease quality physical activity

in schools as a means to combat childhood obesity and evoke the beneficial health, behavioral, and academic outcomes that follow.

4-Phase Approach:> identify> replicate (we are here)

> scale> sustain

PhysicalActivityInnovationCompetition

> UNCOVER the very best approaches to school-time physical activity CELEBRATE & REWARD

champions for the cause from around the country Partnered with

Where do you find innovation?

Fresh Approaches to All School Activity

Students at Red Hawk Elementary participate in an all-school movement break.

Where do you find innovation?

In the ClassroomStudent at PS 102 in East Harlem demonstrate a Just Move classroom break.

Where do you find innovation?

Before SchoolStudents from Simon Elementary, Ward 8, Washington DC enjoying the BOKS program before the bell.

Where do you find innovation?

Fresh ChallengesKids in Corona, CA accept the challenge to run or walk 100 miles over the school year in the 100 Mile Club.

Where do you find innovation?

Inspired ChampionsMom Apryl Krakovsky leads Overland Elementary students through a daily 15 min. morning energizer.

> 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

Campaign Outcomes

Program Mix

Just

Mov

e

0

100

200

300

400

500

600

700

100

Mile

Clu

b

BOKS

Adm

inis

trat

or

Campaign Outcomes

Champion Mix

PE Tea

cher

Teac

her

050

100150200250300350400450500

Pare

nt

Nur

se

Oth

er

> 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

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

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)

What’s Next?

Create 10X impact

From 1,000 to 10,000 schools

www.childobesity180.org