results of steps 1-3 of project - draft version

Using the Evidence-Based Public Health Framework for

Obesity PreventionResults from Steps 1-3:

(1) Community Assessment (2) Quantify the Issue

(3) Develop a concise statement of the issue

February 2012

Evidence-Based Public Health Framework

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

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.

Step 1: Community AssessmentWhat 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

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

Step 1: Community AssessmentWhat 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

Step 1: Community AssessmentWhat 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

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

8


Colorado Demographics – Age

Age Group Total Percent 1% of TotalChildren 0-5 years 413,949 8.2 4,139Children 6-17 years 811,660 16.1 8,116Adults 18-64 years 3,253,962 64.7 32,539Adults 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

http://www.chd.dphe.state.co.us/cohid/Default.aspx


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%20state_2000%202010.pdf

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http://dola.colorado.gov/dlg/demog/2010data/race%20and%20hispanic%20origin%20state_2000%202010.pdf

http://dola.colorado.gov/dlg/demog/2010data/race%20and%20hispanic%20origin%20state_2000%202010.pdf


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


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

http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml


Colorado Demographics – PovertyDemographic 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% 289Below 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

Data source: http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_S1701&prodType=table 13

http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_1YR_S1701&prodType=table

• 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.

14Data sources: http://www.cclponline.org/pubfiles/Colorado%20Poverty%20Factsheet%20FINAL10-14.pdf and http://www.coloradokids.org/facts/kids_count/


Colorado Demographics – Poverty Trends

http://www.cclponline.org/pubfiles/Colorado%20Poverty%20Factsheet%20FINAL10-14.pdf

http://www.coloradokids.org/facts/kids_count/


Colorado Demographics – Child Poverty by County

15Source: http://www.coloradokids.org/facts/kids_count/


16


Colorado Demographics – Child Poverty by Race/Ethnicity

Source: http://www.coloradokids.org/facts/kids_count/


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/



Colorado Demographics – Miscellaneous Demographic Group Total Percent 1% of Total

Female 2,508,534 49.9% 25,085Male 2,520,662 50.1% 25,206Persons 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 with <50,000 population)

708,075 14.1% 7,080

*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

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http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_SF1_QTP1&prodType=table

Step 1: Community Assessment Q2. What are barriers to physical activity and

healthy eating in our community?

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Step 1: Community Assessment Q2. Barriers to Physical Activity and Healthy Eating

Data source: 2009 Colorado Health Marketing Communications Attitude and Behavior Study

Time &

Money

20

Step 1: Community AssessmentQ2. Potential Barriers to Physical Activity

Access Access Access

Data source: 2009 BRFSS

past 30 days

21

Step 1: Community AssessmentQ2. Barriers to Physical Activity

Data source: 2010 CHS

It is difficult for child to be active because…

22

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


23

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

24


• 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


25


• 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


26


• 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

27Source: PANO Stakeholders Input Meeting, September 2011

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?

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• 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

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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


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

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

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

http://about.livewellcolorado.org/sites/default/files/lwc-2010-ann-report.pdf

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

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

http://www.cdc.gov/nphpsp/essentialservices.html

Step 1: Community Assessment Q8. What are the current activities of the public

health system?• Public health improvement plans

(local health agencies)• Physical activity portfolio project• Youth intern project• Joint use agreements• Built environment and land use

planning• Worksite Wellness• Physical activity in schools and

daycare• Early Childhood Obesity

Initiatives

• FDA menu labeling• Smart Meal promotion• Land use planning for local

agriculture, including school and community gardens

• School wellness and healthy eating

• Nutrition portfolio project• Sugar Sweetened Beverage

Research Team• Farm to School Task Force

Source: COPrevent.orgObesity 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.

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• Data gaps: list of partners’ activities

37

Step 1: Community Assessment Data Limitations and Data Gaps

Step 2: Quantify the Issue

38

Step 2: Quantify the issueWhat 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

Step 2: Quantify the issueWhat 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

Step 2: Quantify the issueWhat 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

Step 2: Quantify the issue What questions were answered?

Q1. Obesity prevalence, trend, disparitiesQ2. 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

Step 2: Quantify the issue Obesity

Prevalence, Trends, and Disparities

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)

44BMI: Body Mass Index

Step 2: Quantify the issue Adult Obesity — 2010


45

• 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%).

Step 2: Quantify the issue Adult Obesity Trend

10.1

14.2

21.4

Data source: BRFSS

46

17.8

Significant increase 1995–2010

Step 2: Quantify the issue Adult Obesity by Age

12.8

25.2


47

The prevalence of obesity was higher among adults aged 55-64 years (25.2%) compared with adults aged 18-24 years (12.8%).

Step 2: Quantify the issue Adult Obesity by Race/Ethnicity

20.0

26.5


48

The prevalence of obesity was higher among Hispanic adults (26.5%) compared with White, non-Hispanic adults (20.0%).

Step 2: Quantify the issue Adult Obesity by Income

No difference by income

30.5

19.0


49

30.6

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%).

Step 2: Quantify the issue Adult Obesity by Education

16.2

26.6


50

The prevalence of obesity was higher among adults with less than high school education (26.6%) compared with college graduates (16.2%).

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

51

• 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%

Step 2: Quantify the issueAdult Obesity Disparities Summary


52

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

Step 2: Quantify the issue Child (2–14 years) BMI Categories —

2010

Data source: 2010 Child Health Survey 54

Step 2: Quantify the issue Child (2-14 yrs) Obesity Trend

Data source: CHS55

10.0% overweight

No significant change 2004–2010

56

Step 2: Quantify the issue Child (2-14 yrs) Obesity by Age

www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

http://www.cdphe.state.co.us/pp/COPAN/obesityreport.pdf

57

Step 2: Quantify the issue Child (2-14 yrs) Obesity by Race/Ethnicity



• Children were almost 4 times more likely to be overweight/obese if their parent was obese (2010 CHS)

58

Step 2: Quantify the issue Child/Parent Obesity Association

Step 2: Quantify the issue Physical Activity


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

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

Step 2: Quantify the issuePhysically Inactive Adults – Trend


*Does not include work-related activity

Data source: BRFSS62

20.218.2

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.

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Step 2: Quantify the issueAdult Physical Activity by Quality of Life Measures

Full report available at: http://www.chd.dphe.state.co.us/Resources/pubs/physicalactivity.pdf

http://www.chd.dphe.state.co.us/Resources/pubs/physicalactivity.pdf

Step 2: Quantify the issueAdult Moderate/Vigorous Physical Activity* – Trend

42.9

* Does not get 30+ minutes of moderate PA five or more days/week, or vigorous PA for 20+ minutes three or more days/week

Data source: BRFSS


65

46.8

• 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%

* Does not get 30+ minutes of moderate PA five or more days/week, or vigorous PA for 20+ minutes three or more days/week

Step 2: Quantify the issueAdult Physical Activity* Disparities

Data source: 2010 BRFSS66

Step 2: Quantify the issueCommuting 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 Survey67

Step 2: Quantify the issueAdolescent Physical Activity

Total Male Female 9th

Grade12th

GradeWhite Hispanic

PA 60+min on <5days 53.0 44.9 61.6 50.0 61.3

PA 60+min on <7days 73.1 67.9 79.6No PE 55.0 41.1 62.6No daily PE 79.3No sports team 36.1TV 3+hrs/day 25.1 23.3 13.2 20.0 34.9Computer 3+hrs/day 18.4 29.7 20.5


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* 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.

Step 2: Quantify the issueChild Physical Activity/Inactivity

%

PA <7hrs/week 62.0

No PE 12.7

No daily PE 80.0

No daily walk to school

79.1

TV 2+hrs/day 34.1 weekday70.9 weekend

Computer 2+hrs/day 11.0 weekday10.9 weekend


No physical activity or sports in past week at…

%

School grounds 56.1

Park or playground 31.0

Recreation center 68.7

Street or alley 43.7

69

70

Step 2: Quantify the issueChild Screen Time Trend



71

Step 2: Quantify the issueChild Screen Time by Age



72

Step 2: Quantify the issueChild Screen Time by Sex



73

Step 2: Quantify the issueChild Screen Time by Race/Ethnicity



• 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.

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Step 2: Quantify the issueExample of School Policy

Step 2: Quantify the issue Healthy Eating and Breastfeeding


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.

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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

Step 2: Quantify the issueAdult Fruit/Vegetable Consumption – Trend

75.2

Data source: BRFSS

No significant change 1996-2009

78

73.8

• 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%

Step 2: Quantify the issueAdult Fruit/Vegetable Consumption* Disparities * Consume fruit and vegetables less than 5 times per day


79

80

* Consume fruit and vegetables less than 5 times per day

Step 2: Quantify the issueAdult Fruit/Vegetable Consumption* by BMI



Step 2: Quantify the issueAdolescent Fruit/Vegetable & Soda Consumption

%Fruit/Vegetables <5 times/day 75.6Fruit <2 times/day 66.8Vegetables <3 times/day 83.8Soda 1+ time/day 24.6

• 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

Step 2: Quantify the issueChild Fruit/Vegetable & Soda Consumption

%Fruit and vegetables <5 times/day 81.3< 2 fruit or <3 vegetables per day 90.3Fruit <2 times/day 51.0Vegetables <3 times/day 88.6Sugary drinks 1+ time/day 16.2Sweets 1+ time/day 69.0Fast food 1+ time/wk 63.3Food insecurity 25.3


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Adult prevalence of fast food consumption 1+ time/wk: 64.4%(2009 BRFSS)

83

Step 2: Quantify the issueChild Fruit/Vegetable & Fast Food Consumption Trends



84

Step 2: Quantify the issueChild Fruit/Vegetable & Fast Food Consumption by Age



85

Step 2: Quantify the issueChild Fruit/Vegetable & Fast Food Consumption by

Race/Ethnicity



• 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.

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Step 2: Quantify the issueExample of School Policy

Step 2: Quantify the issueBreastfeeding

%Initiated breastfeeding 88.7Breastfeeding at 6 months 57.7Breastfeeding at 12 months 29.3Breastfeeding exclusively at 3 months

46.8

Breastfeeding exclusively at 6 months

22.5

Data source: 2009 National Immunization Survey (2007 births)

87

88

Percent of Colorado mothers who breastfeed their infants at 6 months of age, 2004–2010

Source: Colorado Child Health Survey, Colorado Department of Public Health and Environment

Per

cent

Step 2: Quantify the issueBreastfeeding at 6 months — Trend

This is not a statistically significant increase from 2004 to 2010.

• 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.

89

Step 2: Quantify the issueBreastfeeding Disparities

Reference: Obesity: Breastfeeding, available at http://www.cdphe.state.co.us/hs/winnableBattles/obesity.html

http://www.cdphe.state.co.us/hs/winnableBattles/obesity.html

• 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

Step 2: Quantify the issue Data Limitations

• 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

Step 2: Quantify the issue Data Gaps

Step 3: Develop a concise statement of the issue

Step 3: Develop a concise statement of the issueWhat 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

Include in the issue statement:–Health condition or risk factor considered–Population affected–Size and scope of the problem–Prevention opportunities–Potential stakeholders

94

Step 3: Develop a concise statement of the issue

What are the considerations?

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.

•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.


• Few (1/14) adult workers use active means to commuteto 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.


• 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.


results of steps 1-3 of project - draft version

Health & Medicine