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Preventing Childhood Obesity: Health in the Balance 6 Local Communities Prevention of obesity in children and youth is, ultimately, about community—extending beyond individuals and families and often beyond geographic boundaries to encompass groups of people who share values and institutions (Pate et al., 2000). In recent years, many public health professionals and community leaders have recognized the need for community involvement in preventing disease and promoting healthful lifestyles. Consequently, they have attempted to capitalize on the naturally occurring strengths, capacities, and social structures of local communities to institute health-promoting change. Many factors in the community setting affect the health of children and youth. Does the design of the neighborhood encourage physical activity? Do community facilities for entertainment and recreation exist, are they affordable, and do they encourage healthful behaviors? Can children pursue sports and other active-leisure activities without excessive concerns about safety? Are there tempting-yet-healthful alternatives to staying-at-home sedentary pastimes such as watching television, playing video games, or browsing the Internet? Are sound food choices available in local stores and at reasonable prices? Communities can consist of people living or working in particular local areas or residential districts; people with common ethnic, cultural, or religious backgrounds or beliefs; or people who simply share particular interests. But intrinsic to any definition of a community is that it seeks to protect for its members what is shared and valued. In the case of obesity prevention in children and youth, what is “shared and valued” is the ability of children
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Preventing Childhood Obesity: Health in the Balance to grow up with healthy and productive bodies and minds. But “to protect” is not necessarily a given. Achieving the vision of Healthy People 2010—“healthy people in healthy communities”—depends on the capacity of communities to foster social norms that support energy balance and a physically active lifestyle (DHHS, 2000b). This report as a whole examines a variety of types of communities and the ways in which improvements can be made in order to foster and promote healthful food and physical activity choices and behaviors. This chapter focuses on the local community, using the term “community” to refer to the town, city, or other type of geographic entity where people share common institutions and, usually, a local government. Of course, within each local community there are many interdependent smaller networks of residential neighborhoods, faith-based communities, work communities, and social communities. The intent of this chapter’s recommendations is not only to make a case for raising the priority of childhood obesity prevention in our communities, but also to identify common interests that can spark collaborative community initiatives for addressing that goal. Many communities and organizations across the United States are actively working to address physical activity and nutrition-related issues; examples are highlighted throughout the chapter (Boxes 6-1 through 6-5). MOBILIZING COMMUNITIES By stepping outside the traditional view of obesity as a medical problem, we may more fundamentally focus on the many institutions, organizations, and groups in a community that have significant roles to play in making the local environment more conducive to healthful eating and physical activity. Table 6-1 illustrates categories of many of the stakeholder groups that could be involved in obesity prevention efforts. For community efforts, key stakeholders include youth organizations, social and civic organizations, faith-based groups, and child-care centers; businesses, restaurants, and grocery stores; recreation and fitness centers; public health agencies; city planners and private developers; safety organizations; and schools. Community-based obesity prevention efforts differ from those of school and home settings (Pate et al., 2000), but potentially supplement and reinforce the messages received in those settings. Young people, particularly adolescents, often spend a large part of their free time in community locales (e.g., recreational or entertainment centers, shopping areas, parks, fast food restaurants). These informal settings, which do not have the stresses of grades or other school situations, may offer environments that are more conducive to trying new activities and foods. Additionally, community settings offer the potential for involving parents and other adult role models in
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Preventing Childhood Obesity: Health in the Balance TABLE 6-1 Examples of Stakeholder Groups in the Prevention of Childhood Obesity Children, Youth, Parents, Families Child- and Youth-Centered Organizations Program, service, and advocacy organizations (e.g., Boys and Girls Clubs, 4H, Girl Scouts, Boy Scouts, YMCA, YWCA, National Head Start Association, Children’s Defense Fund, National Association for Family Child Care) Community-Based Organizations Community coalitions, civic organizations, faith-based organizations, ethnic and cultural organizations Community Development and Planning Architects, civil engineers, transportation and community planners, private developers, neighborhood associations Employers and Work Sites Employers and corporate policy makers, employee advisory committees Food and Beverage Industries, Food Producers, Advertisers, Marketers, and Retailers Corporate and local food producers and retailers (e.g., food and beverage industries, grocery stores, supermarkets, restaurants, fast food outlets, corner stores, farmers’ markets, community gardens) Foundations and Nonprofit Organizations Government Agencies and Programs Federal, state, county, and local elected or appointed decision-makers (e.g., education boards and agencies, public health agencies, parks and recreation commissions, planning and zoning commissions, law enforcement agencies) Health-Care Providers Pediatricians, family physicians, nurses and nurse practitioners, physician assistants, dietitians, occupational-health providers, dentists Health- and Medical-Care Professional Societies Disciplinary organizations and societies Health-Care Delivery Systems Hospitals, health clinics, school-based facilities, work-site health facilities Health-Care Insurers, Health Plans, and Quality Improvement and Accrediting Organizations Public and private health-care providers and insurance reimbursement institutions such as Medicaid and health maintenance organizations; quality improvement and accrediting organizations (e.g., National Committee for Quality Assurance) Mass Media, Entertainment, Recreation, and Leisure Industries Television, radio, movies, print, and electronic media; journalists; commercial sponsors and advertisers; Internet websites and advertisers; computer and video-entertainment industry representatives Public Health Professionals Recreation and Sports Enterprises Local, collegiate, and professional sports organizations; recreation facilities; recreation and sport equipment manufacturers, advertisers, marketers, and retailers Researchers Biomedical, public health, and social scientists; universities; private industry Schools, Child-Care Programs Educators and school administrators, food service personnel, after-school program providers, coaches, school boards, school designers (siting and construction), child-care providers
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Preventing Childhood Obesity: Health in the Balance promoting healthful behaviors (Pate et al., 2000). In enhancing local assets for promoting physical activity—that is, in designing and revamping community facilities and neighborhoods—communities should consider issues related to cultural and social acceptability, availability (proximity), affordability, and accessibility (ease of use). Community Stakeholders and Coalitions Community-Based Interventions: Framework and Evidence Base “Ecological frameworks,” which have been applied across a variety of settings and public health issues to change people or change the environment (Glanz, 1997), suggest that it is important to involve individuals, organizations, communities, and health policy makers in producing desired effects on health (Baker and Brownson, 1998). Given the interactive nature of virtually all elements of a community, most effective interventions act at multiple levels. Moreover, tapping a wide range of local community leaders, organizations, businesses, and residents can result in local ownership of the issue and effectively leverage limited resources (Pate et al., 2000). Community-wide campaigns and interventions. The most relevant evidence for large-scale community-wide efforts comes from studies aimed at reducing cardiovascular risk factors through dietary change and increased physical activity. These interventions have often used multiple strategies, including media campaigns (see Chapter 5), community mobilizations, education programs for health professionals and the general public, modifications of physical environments, and health screenings and referrals; in some cases, home- and school-based interventions were also incorporated (Shea and Basch, 1990). The Stanford Three Community Study, Stanford Five-City Project, Minnesota Heart Health Program (MHHP), Pawtucket Heart Health Program, and North Karelia Project (in Finland) have demonstrated the feasibility of community-based approaches in promoting physical activity and changes in dietary intake (Farquhar et al., 1977, 1990; Maccoby et al., 1977; Luepker et al., 1994; Young et al., 1996; Puska et al., 2002). The results of these studies for adults have been somewhat inconsistent, although modest positive changes in diet and physical activity have generally been seen when a community that received the intervention was compared with one that had not. The strongest positive results were obtained by the extensive North Karelia project, which examined the effects of multiple interventions on the high incidence of coronary artery disease (Pietinen et
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Preventing Childhood Obesity: Health in the Balance al., 2001; Puska et al., 2002). This study, being long-term and multifocal, may be the best model for childhood obesity prevention efforts. MHHP’s Class of 1989 Study provides some insights into the potential impact of community-based programs focused on children and youth (Kelder et al., 1993, 1995). This study examined changes in nutrition and aerobic activity among groups of students, starting when they were sixth-graders and extending through 12th grade. Interventions included a school-based curriculum and a number of other community-based approaches that were not designed specifically for children (including labeling of heart-healthful restaurant and grocery store items; media campaigns; and screening for heart disease risk factors). Positive changes were seen in the young people’s levels of physical activity and their nutritional knowledge and decision-making. Community campaigns aimed at preventing tobacco use by children and youth also provide evidence of the feasibility of using this approach for addressing major public health problems. The Midwestern Prevention Project, the North Karelia Youth Project, and MHHP’s Class of 1989 Study each found reductions in youth smoking rates that were maintained over time (IOM, 1994). It should be stressed that each of these studies had a strong school-based prevention intervention that complemented a community-wide program, and isolating the effects of the community-wide program was not possible. Community programs for children and youth. Programs involving specific community-based organizations have also been found to aid health promotion efforts. Studies with civic, faith-based, and social organizations have established the feasibility of developing programs in a variety of settings that can be effective in improving nutritional knowledge and choices, increasing physical activity, and in some cases in reducing body weight or BOX 6-1 Girls on the Run Girls on the Run is a nonprofit organization that works with local volunteers and community-level councils to encourage preteen girls to develop self-respect and healthful lifestyles through running (Girls on the Run, 2004). A 12-week, 24-lesson curriculum has been developed for use in after-school programs and at recreation centers and other locations. Evaluation of the program has found improvements in participants’ self-esteem, body-size satisfaction, and eating attitudes and behaviors (DeBate, 2002).
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Preventing Childhood Obesity: Health in the Balance maintaining healthy body weight (IOM, 2003). For example, Cullen and colleagues (1997) found that Girl Scouts who participated with their troop in nutrition classes including tasting sessions and materials sent home exhibited increased levels of fruit and vegetable consumption. Furthermore, community programs often are focused on high-risk populations and offer the opportunity to implement culturally appropriate interventions and evaluate their impact (Yancey et al., 2004). Community coalitions. Building coalitions involves a range of public- and private-sector organizations that, together with individual citizens, focus on a shared goal and leverage the resources of each group through joint actions (Table 6-2). It has been pointed out, however, that while the strength of TABLE 6-2 Unique Characteristics of Effective Community Coalitions Characteristic Description Holistic and comprehensive Allows the coalition to address issues that it deems as priorities; well illustrated in the Ottawa Charter for Health Promotion Flexible and responsive Coalitions address emerging issues and modify their strategies to fit new community needs Build a sense of community Members frequently report that they value and receive professional and personal support for their participation in the social network of the coalition Build and enhance resident A structure is provided for renewed civic engagement in community life engagement; the coalition becomes a forum where multiple sectors can engage with each other Provide a vehicle for community empowerment As community coalitions solve local problems, they develop social capital, allowing residents to have an impact on multiple issues Allow diversity to be valued and celebrated As communities become increasingly diverse, coalitions provide a vehicle for bringing together diverse groups to solve common problems Incubators for innovative solutions to large problems Problem solving occurs not only at local levels, but at regional and national levels; local leaders can become national leaders SOURCE: Adapted from Wolff, 2001.
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Preventing Childhood Obesity: Health in the Balance coalitions is in mobilizing the community to work for change, they are not generally designed to develop or manage specific community services or activities (Chavis, 2001). Community collaborative efforts focused on health are of growing interest across the United States. Models are being refined on ways to link community organizations, community leaders and interested individuals, health-care professionals, local and state public health agencies, and universities and research organizations (Lasker et al., 2001; Lasker and Weiss, 2003). Community coalitions have played significant roles in efforts to prevent or stop tobacco use. The American Stop Smoking Intervention Study (ASSIST), which was funded by the National Cancer Institute and featured the capacity building of community coalitions, targeted tobacco control efforts at the state and local levels. States with ASSIST programs had greater decreases in adult smoking prevalence than non-ASSIST states (Stillman et al., 2003); factors identified as contributing to participation and satisfaction with the ASSIST coalitions included skilled members and effective communication strategies (Kegler et al., 1998). Coalition building and community involvement also have been effective in community fluoridation efforts (Brumley et al., 2001). Health Disparities Although this report focuses primarily on population-wide approaches that have the potential to improve nutrition and increase physical activity among all children and youth, the committee recognizes the additional need for specific preventive efforts. Children and youth in certain ethnic groups including African-American, Mexican-American, American-Indian, and Pacific Islander populations, as well as those whose parents are obese and those who live in low-income households or neighborhoods, are disproportionately affected by the obesity epidemic (Chapter 2). Many issues—including safety, social isolation, lack of healthy role models, limited access to food supplies and services, income differentials, and the relative unavailability of physical activity opportunities—may be barriers to healthier lifestyles for these and other high-risk populations. Moreover, as discussed in Chapter 3, perceptions about body image and healthy weight can vary between cultures and ethnic groups, and these groups can manifest differing levels of comfort with having an elevated weight. Furthermore, there may be a “communication gap” in making information about the health concerns of childhood obesity widely available. As a result, culturally appropriate and targeted intervention strategies are needed to reach high-risk populations. There are examples of these types of strategies having positive results. For example, a 10-county study of churches participating in the North Carolina Black Churches United for
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Preventing Childhood Obesity: Health in the Balance Better Health project found that church-based interventions (including group activities, changes in food served at church events, and dissemination of educational materials) resulted in increased fruit and vegetable consumption by adults participating in the intervention (Campbell et al., 1999). Pilot studies from the Girls Health Enrichment Multi-site Study (GEMS), a research program designed to develop and test interventions for preventing overweight and obesity in African-American girls, have included a variety of community, after-school, and family-based components in a range of settings (Baranowski et al., 2003; Beech et al., 2003; Robinson et al., 2003; Story et al., 2003). For example, the Stanford GEMS pilot study in 61 families tested a model that combined after-school dance classes for girls with family-based efforts to reduce time spent watching television. Positive trends were observed regarding body mass index (BMI), waist circumference, physical activity, and television viewing in the treatment group when compared to the control group (Robinson et al., 2003). These studies demonstrate the feasibility of implementing relevant community programs; two of these studies have been expanded to evaluate programs with larger study populations over a 2-year period (Kumanyika et al., 2003). However, much remains to be learned about interventions that can reduce or alleviate the risk factors for childhood obesity in high-risk populations. Prevention efforts must be considerate of culture, language, and inequities in social and physical environments (PolicyLink, 2002). Furthermore, because these populations traditionally have been disenfranchised, special efforts must be made to gain their trust, both among individuals and at the community level. The 39-community Partnership for the Public’s Health project in California and other community-centered public health initiatives have demonstrated that the most progress is made when an intervention engages community members themselves in the program’s assessment, planning, implementation, and evaluation (Partnership for the Public’s Health, 2004). Private and public efforts that work to eliminate health disparities should include obesity prevention as one of their primary areas of focus. Some of the many ongoing efforts span the public and private sectors as well as the local, regional, state, and national levels and focus on diabetes and other chronic diseases for which obesity is a risk factor. For example, the Centers for Disease Control and Prevention’s (CDC’s) REACH 2010 initiative has broad-based collaboration within the U.S. Department of Health and Human Services (DHHS) and the private sector (CDC, 2004b) to fund and support demonstration projects and community coalitions focused on eliminating health disparities. Each coalition includes community-based organizations and the local or state health department or a university or research organization. Efforts to date have included community and tribal efforts to address diabetes and cardiovascular disease risk factors.
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Preventing Childhood Obesity: Health in the Balance These efforts should aim to increase access to culturally and linguistically appropriate nutritional and physical activity information and skills and should support community-based collaborative programs that address the inequities in obesity rates between populations. The communities themselves, meanwhile, need to involve all segments of the local population in developing both community-wide interventions and those that focus on high-risk populations. Furthermore, local communities—with the assistance of state and federal governments, nonprofit organizations, and the private sector—need to grapple with the underlying and long-standing socioeconomic barriers that result in limited opportunities for physical activity (e.g., safe parks and playgrounds) and affordable healthful foods (e.g., produce markets or large grocery stores). Opportunities to foster such coalitions and to develop effective programs for high-risk populations will be widened if there is grassroots participation by the citizens most affected by the problem. Next Steps for Community Stakeholders Many community organizations are currently involved in efforts to improve the well-being of their children and youth regarding a number of health and safety concerns, such as tobacco and alcohol abuse, sexually transmitted diseases, pedestrian and bike safety, and prevention of motor BOX 6-2 Kids Off the Couch Kids Off the Couch is a community collaborative pilot project in Modesto, California, that works with parents and caregivers to prevent obesity in children up to 5 years of age. The project’s goal is to influence behavioral changes in food selection and physical activity among parents and primary caregivers. The program provides parents and caregivers with: Information on the risks of childhood obesity Tools to assist their children in achieving normal growth and healthy development Hands-on demonstrations on how to prepare healthful and tasty foods that families will eat and enjoy Instruction on how to engage their families in physical activity. This project is a collaborative effort of numerous partners including the local school system, health services agency, hospitals, and health clubs; the American Cancer Society; Blue Cross of California; and the University of California Cooperative Extension.
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Preventing Childhood Obesity: Health in the Balance vehicle injuries. Increased media coverage and the voices of concerned individuals and groups should now be prompting these community groups and others, including the broad range of stakeholders they work with, to focus on childhood obesity prevention. In particular, there is a need to galvanize action and expand opportunities for healthful eating and physical activity at the community level. Community youth organizations can have an impact not only by adapting their own programs to include emphasis on healthful eating and physical activity, but also by joining with other organizations to form coalitions to promote community-wide efforts. Additionally, innovative approaches to community recreational programs are needed. Traditional organized competitive sports programs are an important facet of the community and offer physical activity opportunities for many children and adolescents. However, competitive sports programs are not of interest to all individuals and it is important to expand the range of options to include not only team and individual sports but also other types of physical activity (e.g., dance, martial arts) (CDC, 1997b). It will also be important to help families overcome potential obstacles—including transportation, fees, or special equipment—to program participation (CDC, 1997b). Community youth organizations (such as Boys and Girls Clubs, Girls Scouts, Boy Scouts, 4H, and YMCA) should expand existing programs and establish new ones that widen children’s opportunities to be physically active and maintain a balanced diet. These programs should complement and seek linkages with similar efforts by schools, local health departments, and other community organizations. Furthermore, evaluation of these programs should be encouraged. Employers and work sites are another important component of community coalitions. The work site affects children’s health both indirectly, through its influence on employed parents’ health habits, and directly, through programs that may engage the entire family. Workplaces should offer healthful food choices and encourage physical activity. In businesses where on-site child care is provided, attention should be paid to ensuring that children have a balanced diet and adequate levels of physical activity. Local organizations, businesses, local public health agencies, and other stakeholders increasingly have been joining together to address health issues through community coalitions, wherein the sum is greater than the parts, and meaningful progress on an issue becomes more likely. Coalitions can make obesity prevention a local priority and can design and implement programs that best fit the local area. It is important for coalitions to be inclusive, promote broad involvement, and represent as many constituencies as possible (see Table 6-2). As coalitions become established, it is also important for them to periodically reassess their status to ensure they remain inclusive and do not outlive their usefulness. Because of their nature,
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Preventing Childhood Obesity: Health in the Balance coalitions exhibit wide variation in their structure and in the range of organizations, agencies, and individuals involved. However, to be sustained all require strong and ongoing leadership that is selected by coalition members. Communities should establish and promote coalitions of key public and private stakeholders (including community youth organizations, local government, state and local public health agencies, civic and community groups, businesses, faith-based groups) to address the problem of childhood obesity by increasing the opportunities for physical activity and a balanced diet. Partnering with academic centers will be important for community-based research. To have a long-term and significant impact on the public’s health, community health initiatives should include programs that work towards initiating changes at many levels including changes in individual behaviors, family environments, schools, workplaces, the built environment, and public policy (Kaiser Permanente, 2004). This ecologic approach (see Chapter 3) is a critical part of a framework for community-level initiatives that support a health-promoting environment. Communities should seek to undertake a comprehensive, interrelated set of interventions operating at each ecological level and in multiple sectors and settings. Factors that have been found to be involved in sustaining successful community change efforts include a large number of environmental changes focused on a small number of categorical outcomes; intensity of behavior change strategy; duration of interventions; and use of appropriate channels of influence to reach appropriate targets (Fawcett et al., 2001). Community-level approaches are among the most promising strategies for closing the disparities gap (PolicyLink, 2002; Prevention Institute, 2002). These strategies include improvements in the social and economic environment (e.g., through the creation of health-promoting social norms, economic stability, and social capital development), the physical environment (e.g., access to affordable healthful food and physical activity resources), and community services (e.g., after-school programs) (Prevention Institute, 2003). The goals of improving community health and addressing racial and ethnic health disparities are closely aligned. The committee acknowledges the limited amount of empirical research that directly examines the effects of changes in community programs or formation of coalitions on obesity prevalence. However, interventions such as GEMS demonstrate the feasibility of these interventions, and the experience gained in other public health areas provides additional support for recommendations in these areas. As with other types of obesity prevention interventions (noted throughout this report), there is a critical need to ensure that community intervention programs are thoroughly evaluated. The impacts of coalitions have sometimes gone undetected because of inap-
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Preventing Childhood Obesity: Health in the Balance risk populations, who often live in areas where easy access to recreational facilities is lacking or where costs are prohibitive. For the providers of health-care services, it is important that obesity prevention (including assessment of weight status as well as counseling on nutrition and physical activity) become a routine part of clinical care. Moreover, measures related to successful delivery of clinical preventive services, such as rates of screening tests, should be important components of healthcare quality-improvement programs that are promoted by health plans. The National Committee for Quality Assurance (NCQA) and other national quality-improvement and accrediting organizations should add obesity prevention efforts—such as routine measurement and tracking of BMI, counseling of children and their parents on diet and exercise—to the measures they develop and assess. There may also be opportunities for incorporating obesity prevention measures and counseling into ongoing federal, state, and local programs that provide disease prevention and health promotion services to children. For example, Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment program offers preventive screenings for eligible children (generally in underserved populations) and it includes a comprehensive health and developmental history. More than 8.7 million children participated in the screening program in 1998 (CMS, 2004), thus offering many potential opportunities for obesity prevention in children. As with other sectors, those involved in delivering and paying for health care need to become more proactive, preferably through a multifocal, coordinated set of initiatives, in working with families to promote physical activity and healthful diets among children. Medicare has recently removed barriers to coverage for obesity-related services (DHHS, 2004). Although this, of course, does not relate directly to children, it is an action that may well be emulated by other insurers and for preventive services as well as for treatment. Health insurers, health plans, and quality-improvement and accrediting organizations should designate childhood obesity prevention as a priority health promotion issue. Furthermore, health plans and health-care insurers should provide incentives to individuals and families to maintain healthy body weight and engage in routine physical activity. Health insurers, health plans, and quality improvement and accrediting organizations (such as NCQA) should include screening and obesity prevention services (e.g., routine assessment of BMI or other weight-status measures, counseling of children and their parents on nutrition and physical activity) in routine clinical practice and in quality assessment measures relating to health care.
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Preventing Childhood Obesity: Health in the Balance Recommendation The health-care community offers a range of opportunities for interactions with children and youth regarding obesity prevention. Several controlled trials of counseling by health-care providers have resulted in patient improvements in physical activity levels or diet, although these studies have generally been conducted with small numbers of patients and have focused on counseling of adult patients. Further research is needed on effective counseling or other types of obesity prevention interventions that could be provided in health-care settings. Improved professional education regarding obesity prevention is an important next step, as is the active involvement of health professional organizations, insurers, and accrediting organizations, in making childhood obesity prevention efforts a priority. Recommendation 8: Health Care Pediatricians, family physicians, nurses, and other clinicians should engage in the prevention of childhood obesity. Health-care professional organizations, insurers, and accrediting groups should support individual and population-based obesity prevention efforts. To implement this recommendation: Health-care professionals should routinely track BMI, offer relevant evidence-based counseling and guidance, serve as role models, and provide leadership in their communities for obesity prevention efforts. Professional organizations should disseminate evidence-based clinical guidance and establish programs on obesity prevention. Training programs and certifying entities should require obesity prevention knowledge and skills in their curricula and examinations. Insurers and accrediting organizations should provide incentives for maintaining healthy body weight and include screening and obesity preventive services in routine clinical practice and quality assessment measures. REFERENCES AAFP (American Academy of Family Physicians). 2004. Americans in Motion. [Online]. Available: http://www.aafp.org/x22874.xml [accessed May 14, 2004]. AAP (American Academy of Pediatrics), Committee on Sports Medicine and Fitness and Committee on School Health. 2000. Physical fitness and activity in schools. Pediatrics 105(5):1156-1157. AAP. 2001. Children, adolescents, and television. Pediatrics 107(2):423-426.
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Representative terms from entire chapter: