Patricia Coleman, Nutrition and Health Programs Team Leader

PREVALENCE OF YOUNG CHILD OVERWEIGHT AND OBESITY IN THE US AFFILIATED PACIFIC REGION: A META ANALYSIS FROM THE CHILDREN’S HEALTHY LIVING PROGRAM (CHL)*

RACHEL NOVOTNY1, MARIE KAINOA FIALKOWSKI1, FENFANG LI1, DONALD VARGO2, YVETTE PAULINO3, PATRICIA COLEMAN4, ANDREA BERSAMIN5, CLAUDIO R NIGG1, JODI LESLIE1, RACHAEL LEON GUERRERO3, JONATHAN DEENIK1, JANG KIM4, LYNNE R WILKENS11UNIVERSITY OF HAWAII, 2AMERICAN SAMOA COMMUNITY COLLEGE, 3UNIVERSITY OF GUAM, 4NORTHERN MARIANAS COLLEGE, 5UNIVERSITY OF ALASKA, FAIRBANKS

Introduction: US NHANES is not conducted is US Affiliated Pacific (USAP) Region (USAP Islands, Hawai`i , Alaska).Method: A meta-analysis of published literature and publicly available agency reports was conducted to estimate overweight and obesity prevalence of 2-8 year (y) old USAP children. Contiguous US data (NHANES) served as reference. Literature search was limited to resources in English and 2-8y USAP children data from 2000 to 2013 and used CDC 2010 overweight and obesity reference data. USAP region sources (n=23) and NHANES articles (n=3; the contiguous U.S reference) included. Data were disaggregated into single years of age. The children measured for the age group were divided equally and the prevalence was assigned to each individual age. A mixed model regressed the prevalence on a polynomial in age, accounting for the prevalence variance and another model compared jurisdictions. Results: Overweight plus obesity increased from 21% at 2y, to 39% at 8y (p<0.0001) for the USAP. In comparison, combined overweight plus obesity increased from 24 % at 2y to 35% at 8y (p<.0001) for NHANES. USAP data showed with a sharp increase in prevalence at 5y. Obesity alone increased from 10% at 2y, doubling to 24% at 8y (p<0.0001)whereas overweight prevalence was stable from 2y (13%) to 8y (15%). Discussion: Further examination, monitoring and understanding of USAP young child obesity is needed.

*TO BE PRESENTED AT AMERICAN SOCIETY OF NUTRITION ANNUAL MEETING IN SAN DIEGO, APRIL 2014 & ABSTRACT PUBLISHED IN  FASEB JOURNAL.  PAPER SUBMITTED TO AJPH.

•

Methods

• Meta-analysis of published literature and publicly available agency reports for Hawaii, Alaska, and US-Affiliated Pacific Islands

• English only, 2-8 year olds • Year 2000 & newer, CDC overweight and

obesity reference data• Data disaggregated into single years of age

Methods cont.

• Children measured for the age group were divided equally and prevalence was assigned to each individual age

• Mixed model regressed the prevalence of a polynomial in age

Results

• OWOB increased from 21.0% at 2y to 39.2% at 8y (p<.0001) for the USAP

• NHANES increased from 24.2% at 2y to 34.8% at 8y (p<.0001)

• Sharp increase in prevalence at age 5y• USAP obesity alone increased from 10.2% at

2y to 23.6% at 8y (p<.0001)

CHL Population

U.S. Affiliated Pacific Region Need

• Obesity - minimal data, no NHANES• Capacity - few trained professionals• Unique geography and culture - need

culturally tailored approach

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CHL Annual Meeting, Guam June 2013

CHL VisionWe envision sustainable community-based systems and environments to raise healthy

children in the Pacific Region

Children from the Republic of the Marshall Islands

CHL MissionIn partnership with our

community, our mission is to elevate the capacity of the

region to build and sustain a healthy food and physical

environment to help maintain healthy weight and prevent

obesity among young children in the Pacific region

Tafuna Elementary,

American Samoa,

April 2013

CHL Goal

The goal of CHL is to build social/cultural, political/economic, and physical/built

environments that will promote active play and intake of healthy food to prevent young

child obesity in the Pacific Region

Children from Yap State, Federated States of Micronesia

External Advisory CommitteeJennifer Anderson

Kathryn KolasaSuzanne MurphyWendy SnowdonBoyd Swinburn

Principal Investigator

Novotny

Program Steering Committee Lead Site Co-I :

Deenik, Kim, Bersamin, Leon-Guerrero/Barber, Novotny,

Vargo/Ropeti

External Communication Center Lead: Hollyer / Takahashi

Coordinating Center Program Director: NovotnyAssistant Program Director: FialkowskiProgram Administrator: YanConference Coordinator: ChunIT Manager: DeBusk

Data Center Lead: Wilkens

Data Coordinator: LiPerformance Sites FAS: FSM, RMI, Palau;

CNMI; Alaska; Guam; Hawaii; Am. Samoa

Local Advisory Committees LG Dir. Chair:

Currie, Samson, Taro;

Manglona; Sparrow, Yudin, Gallo, Aga

CHL Management Structure

Training / Education Center Lead: Dunn / Fialkowski

Education Coordinator: Leslie / Delormier

Intervention Center Lead: Nigg / Braun

Intervention Coordinator: ButelSituation Analysis Center

Lead: Fialkowski / DeBaryshe

CHL Target Population• Grant requirement: children ages 2 – 8 y

– Head Start – Preschool– Day Care– Kindergarten– Community Health Centers– Community Centers– Community Events– Supplemental Feeding Program for Women, Infants, &

Children

Images from CHL brochure, courtesy of Center on the Family

CHL Objectives1. Conduct program / data inventories & situation analysis – Situation Analysis 

Work Group

2. (Degree) Train 22 professionals & paraprofessionals in obesity prevention – Training Work Group

3. Develop Pacific food, nutrition & physical activity data management & evaluation system – Data & External Communications Work Groups

4. Develop & conduct an environmental intervention (to prevent, maintain or decrease young child overweight & obesity in the Pacific Region) – Intervention and External Communication Work Groups

5. Evaluate the community - based primary - prevention environmental intervention – Data Center Work Group

6. Incur at least one obesity prevention policy change per state / jurisdiction – Program Steering Committee Work Group

CHL (6 behavioral outcomes, 3 health outcomes)Primary

1. Sleep by 15 min/day2. Moderate to vigorous physical activity by 10

min/day 3. Fruit & vegetable intake by 1 serving/day (1/2

c/day)4. Water intake by ½ cup/day

5. Sedentary behavior (screen time) by 10 min/day6. Sweetened beverage intake by ½ cup/day1. Prevalence of obesity by 8% (0.10 kg/m2 decrease in

BMI z- score)2. Waist circumference by 2%

Secondary3. Acanthosis nigricans by 5% Positive acanthosis nigricans

screen, CHL Study

Effective Evidence-Based Strategies from Randomized Controlled Trials

Decrease in SSB intake

Increase in F/V intake

Increase in water intake

Decrease in leisure screen

time

Increase in PA

Increase in sleep

Policies to ban SSB

Product & shelf labeling

Healthy lifestyle

Education

Policies: promote F/V consumption

Product & shelf

labeling

Gardening

Healthy lifestyle

education

Policies to promote water

intake

Increase access to

clean Water

Healthy lifestyle

education

Policies to reduce screen

time

Healthy lifestyle

education

Policies to promote PA

Change Built Environment

to promote PA

Healthy lifestyle

education

Healthy lifestyle

education

ANGELO –Analysis Grid for Elements Linked to Obesity (Swinburn and colleagues)

CHL SITUATIONAL ANALYSIS & SCAN MERGE

PRIORI-TIZE

FORMU-LATE

GOALS

Demographic, health, risk, and other data

Community suggestions to address obesogenicenvironments Physical Social Policy

Scientific literature

Strategies from:

Community

Literature

Importance

Do-ability

Action Plans

Healthy Eating1. Decrease in SSB

intake

2. Increase in water intake

3. Increase in fruit & vegetable intake

Physical Activity4. Decrease in

leisure screen time

5. Increase in sleep

6. Increase in physical activity

Top Strategies from Communities (Nov 2011-Feb 2012)

Overall Priorities Alaska Am Sam CNMI Guam Hawaii1. Educate parents, siblings, grandparents, children, communities on healthy living X X X X X

2. Importance of family, teachers, leaders, other respected figures as role models setting a healthy living example X X X X

3. Better and more free community activities and resources to promote healthy living X X X X X

4. Community resources maintained and accessible during all times making physical activity easier X X X X

5. Improve drinking water access/facilities X X X X

6. School policies need to be changed to make school lunches healthier, encourage water intake, increase physical activity, and reduce sugar sweetened beverage

X X X X

7. Change government policies to promote healthy lifestyle, prohibit use of food stamps to buy junk food, control stray dogs and moose

X X X X

8. Limit screen time X X9. Healthy local-grown, garden-fresh produce should be easily accessible and affordable

X X X X X

MERGE -- Much of what the community wants is supported by the literature

Supported by literature

Supported  by community

Policies X XAccess to water X XEnvironmental changes for PA X XHealthy living education X XProduct and shelf labeling XAccess to affordable produce (including gardening)

X X

PRIORITIZE - Communities prioritized the merged list of strategies (May-June 2012)

Merged list of strategies posted on flip chart paper

Presented to 10 selected communities, 2 each in:• Alaska• American Samoa• CNMI• Guam• Hawaii

Participants prioritized based on• Importance• Feasibility (Do-ability)

FORMULATE– Intervention Community Action Planning (LAC)

1. Bring together key stakeholders, including parents, teachers, and leaders to implement the strategy

2. Adapt the strategy to the locale

3. Promote and implement the strategy

4. Establish a mechanism to monitor fidelity and outcomes

5. Use data to improve implementation

Other communities are testing interventions to reduce childhood obesity,

ANDthey are willing to share their materials and ideas!

In implementing these strategies, CHL:

• Partners with, supports, and “adds value” to existing programs that are conducting activities related to our 6 behavioral outcomes.

• Builds local capacity to sustain programs and policy changes.

• Promotes a common CHL message.• Collects data on the timeline of implementing strategies

and on the extent to which strategies are implemented at given time points.

Cross-cutting Functions

1. Review assessment data for policy & physical environment related to the 6 CHL behaviors

2. Partner & advocate for environmental change

3. Promote the CHL message

4. Train the trainers

CHL Intervention: Cross-Cutting Functions, Activities & Behavioral Targets ↓SSB

↑F/V

↑PA

↑Water

↓Screen

↑Sleep

Review Assessment Data for Policy & Physical Environment related to the 6 CHL behaviorsa. Review preschool wellness policy assessment data to identify training needsb. Review community assessment data to identify areas for advocacy for PA env.

XX

XX

XX

XX

X X

Partner and Advocate for Environmental Change a. Work with coalitions to advocate for 

i. Better access to parks that are safe & invitingii. Better access to clean wateriii. Safer environments for walking & bikingiv. Better food placement in storesv. Gardens & hydroponics

b. Partner with existing entities to purchase or obtain sponsorship fori. Water in the preschoolsii. Gardening supplies for preschool kidsiii. Sports equipment for preschool kidsiv. Campaigns & messages

X

X

X

X

XX

X

X

X

X

X

XXX

X

X

X

X X X

Promote the CHL Message a. Support role models to deliver CHL messages in variousb. Enhance existing social marketing campaigns related to 6 CHL behaviorsc. Advertise CHL or other activities that promote 6 CHL target behaviors

XXX

XXX

XXX

XXX

XXX

XXX

Train the Trainers a. Train individuals to promote gardening in preschools & communitiesb. Train individuals to lead interactive, hands-on, & family-based sessionsc. Train preschool providers on wellness policiesd. Train preschool providers in curricula related to 6 CHL target behaviors e. Train role models (community champions, role celebrities, role models)

XXXXX

XXXXX

XXXXX

XXXXX

XXXXX

XXXXX

CHL TEAM CNMI

Jang Ho Kim, Tayna Belyeu-Camacho, Rose Castro, Jesse Deleon Guerrero, Marilynn Duenas, Randall Nelson, & me

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CNMI work w/role models (RM)

• Village focused instead of CNMI-wide focus• RM identified by key informants, knowledge of

community • Empowerment of stakeholders/role models• Training and technical support • Building on assets, strengths, influences of role

model group—integral role in driving the intervention

• Diverse backgrounds

Village Logos

TASA Role Models

Enhancing the Built Environment in Kagman

Policy: Child Care Licensing RegulationsPolicy & Advocacy 

• Require each child care center to have policies that focus on the implementation of the CHL behaviors

• Require procedures/plans for implementation

• Align inspection checklist with policy requirements

• Mobilize partners for support

• Get approval from governor

Training • First training slated for May-

demonstrate burden of COWOB, critical role they play-get buy-in

• Include child care administrators, owners, managers, and child care providers

• Write the policy in • Subsequent trainings to focus on

implementation of one or two CHL behaviors

• CCDF benefits

Prevalence SurveyFreely Associated States: Palau, Marshalls, Chuuk, Kosrae, Pohnpei, Yap

• Determine the prevalence rates of underweight, overweight, and obesity in a representative sample of young children, ages 2 – 8y, from each jurisdiction

• Provide descriptive information on similar measures as CHL Intervention Study

• Approximate sample size 200 per jurisdiction Marshalls, Kosrae, Pohnpei, Chuuk, Yap, Palau)

• Data: Anthropometry, Acanthosis Nigricans, Accelerometry, Questionnaire (Sleep etc...),Food and Activity logs, Community obesity prevention environmental assessment, Food & Utility cost survey

• Most Survey elements completed in Pohnpei (Oct 28-Nov 8, 2013) and RMI ( Jan 1-Feb 4, 2014)

• Palau survey: April 7-18, 2014; Chuuk Survey July 14 to Aug 14, 2014; Yap October 2014; Kosrae Jan 2015

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I.  CHL Scholarship Program

Provide academic degree training for indigenous students in CHL region- 2 from each jurisdiction, including 2 from each state of Freely Associated States of Micronesia

II.  CHL Capacity Building Program for the Pacific Region          Help develop sustainable, culturally appropriate, nutrition courses & programs & within existing academic institutions in the region

Capacity Building Through Training

CHL Students – Cohort 1

CHL Students – Cohort 2

CHL PhasesPhase 1: Situation

Analysis

• Inventories• Community

Meetings• Community

Readiness

Phase 2: Measurement

•Participant•Community•Data entry

Phase 3: Intervention

• Implementation •Monitoring•Data entry

Phase 4: Measurement

•Participant•Community•Data Entry

Phase 5: Evaluation, Dissemination, Policy

& Data Systems Development

Trai

ning

3,919

PhysicalActivity

•Decrease in recreational screen time•Increase in sleep•Increase in physical activity

HealthyFood Intake

•Decrease in sugar-sweetened beverage intake•Increase in water intake•Increase in fruit and vegetable intake

Children’s Healthy Living Program

Obesity Preventio

n

Overall Outcome

: Healthy Young Child

Environmental Changes

Promote Outcomes

Political/Economic Env.Examples:•Influence leash laws

Physical/Built Env.Examples:•Ensure water fountains are available & maintained

Social/Cultural Env.Examples:•Family, teachers, church leaders, other respected role models setting example of healthy living

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Community-Based 

Environmental Intervention 

& Policy Change

Data Systems

Training/Education

Si yu’us maase yan olomwaay!