The Culture Politics and Economics of Our Obesogenic Society

The Culture, Politics and Economics of Our ―Obesogenic‖ Society & How to Fix It Antronette K. Yancey, MD, MPH, FACPM Associate Professor, UCLA School of Public Health Summary Points     Current strategies are not containing the obesity and sedentariness epidemics Need shift away from clinical view of obesity as personal disorder requiring medical Rx An ecological approach regards obesity as a normal response to an abnormal environment, rather than vice versa Understanding, measuring, and altering the ―obesogenic‖ environment is critical—society has key role in sharing, with individuals, the high ―costs‖ of healthy lifestyle change/maint. Obesity Trends* Among U.S. Adults BRFSS, 1985 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. Obesity Trends* Among U.S. Adults BRFSS, 1990 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. Obesity Trends* Among U.S. Adults BRFSS, 1995 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. Obesity Trends* Among U.S. Adults BRFSS, 2001 Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. Prevalence of Overweight Among U.S. Children and Adolescents Ages 6-19 Years 16 14 12 11 11 7 5 15 15 Percent 10 8 6 4 2 0 1963-70 1971-74 6-11 Years 1976-80 1988-94 1999-00 4 5 6 4 12-19 Years SOURCE: CDC/NCHS, NHES and NHANES Center for Public Health Advocacy An Epidemic of Unfit and Overweight Children http://www.publichealthadvocacy.org/ REGIONAL HEALTH EDUCATION Excess physical environmental risk in underserved communities:       targeted/exploitative marketing excess fast food outlets few supermarkets limited shelf choices high-fat food availability (home, church poorer public/less pvt transportation      distance to private fitness facilities few worksite fitness opportunities few/poor neighborhood recreation facilities lesser neighborhood safety poorer public/less pvt transportation Excess economic environmental risk in underserved communities      low neighborhood demand for healthy food choices low family incomes other household expenses little homegrown food financial incentives for under-resourced schools by commercial vendors        limited investment in parks/rec facil. fitness facility fees cost of exercise equipment less stable employmt patterns fewer trained PE instructors large PE classes poorly equipped facil. Excess sociocultural environmental risk in underserved communities       traditional cuisine fasting-feasting prevalent obesity/norms body image female roles (perceived) food insecurity      cultural attitudes about PA, rest fears about safety female roles cultural reverence for cars hairstyle-related concerns about sweating Overweight Rates, % L.A. County Adults District 1997 1999 County South 47 62 +1 +8 +8 +6 52 68 74 56 +1 +8 +9 +7 Comptn 59 Inglewd 49 Lng Bch 46 West 38 +6 +4 51 42 +6 +4 Physical Activity Levels, % L.A. County Adults, 1999 District Sedentary (<10 min/wk) County Compton South Inglewood 41 45 50 46 +1 +6 +9 +6 Long Beach West 37 31 +5 +3 Weight Status by Ethnicity & Gender, % LA County Adults 36 30 42 25 BMI<25 25 to<30 Obese Afr-Am female male API 40 42 38 67 25 28 21 8 female male 78 57 15 36 8 8 Weight Status by Ethnicity & Gender, % LA County Adults (cont.) BMI<25 25 to<30 Obese Latino female male White 36 42 30 51 44 35 52 34 20 23 18 16 female male 60 42 24 43 17 14 Weight Status by Sexual Orientation, % LA County Adult Women Overwt (Lesbian/bisexual Heterosexual) Obese (Lesbian/bisexual Heterosexual) African-American 73.0 39.7 40.3 Asian-American 31.9 15.8 8.3 12.3 Latina/Hispanic 58.5 4.1 35.8 41.8 White 50.5 17.5 22.9 38.9 16.4 Mays, Yancey et al., AJPH, 2002 Self-Perceived Overweight by Ethnicity & Gender, % LA County Adults Female 67 20 86 28 80 26 84 21 AA Overwt AA Nml wt API Overwt API Nml wt Lat Overwt Lat Nml wt W Overwt W Nml wt Male 29 -46 10 41 9 46 4    % LA County Adults Across racial/ethnic groups, regardless of BMI, those perceiving themselves as overweight more sedentary than those with average wt. self-perception (45% vs. 30%) Influence most pronounced for males and normal weight individuals In multivariate analysis, self-perceived overweight, not BMI, predicts sedentary behavior (OR=1.40, CI 1.19, 1.64) Influence of Self-Perceived Weight Status on PA, Yancey, Wold et al., in preparation, 2003 A small behavior change over time can create/prevent some weight problems. Energy Input vs Energy Output 2% Error Leads to Obesity 125 kj/day or 15 Minutes of Play Instead of Television Michael Goran, Am J Clin Nutr 1999;70 Population benefit estimates of risk factor change: weight   Weight loss of 8-15 lbs or 5-10% would decrease Type 2 diabetes risk by 30-60%, without achieving ideal body weight Modest weight loss normalizes BP (Resnick et al., 2000), elevates mood and relieves anxiety (Wadden et al., 1996) --5% reduction in SBP would reduce stroke incidence by 30% (Law et al., 1991) --2% decrease in DBP would decrease CHD risk by 6%, stroke/TIA by 15% (Cook et al., 1995) Population benefit estimates of risk factor change: PA    If the entire U.S. population increased its PA level by 30 min. of brisk walking/day, colon CA incidence would decrease by 15% (Colditz et al., 1997), stomach CA by 5- to 6-fold (Terry et al., 1998), and CHD risk by 30-40% in women (Manson et al., 1999) Maintenance of moderate PA is assoc. with a 1/3 to 2/3 lowering of Type 2 diabetes incidence over 4-14 yrs (Clark, 1997) Type 2 diabetes risk was 50% lower among individuals physically active at any level, and 66% lower among those at least moderately active (James et al., 1998) Physical Fitness and Academic Performance The California Department of Education studied 353,000 fifth graders, 322,000 seventh graders, and 279,000 ninth graders across the state to see whether 2001 SAT-9 performance was related to results of the state-mandated physical fitness test (the Fitness-gram), measuring:       Aerobic capacity Body fat composition Abdominal strength Trunk extension strength Upper body strength Flexibility. th 5 Grade – SAT9 percentile and Fitness Performance 80 70 71 58 45 36 29 40 32 36 40 50 46 55 Reading Math 60 50 40 30 20 10 0 1 2 3 4 5 6 SAT 9 Percentile Number of Fitness Standards Achieved “Very Promising” Evidence-Based Overweight Intervention Strategies Physical Activity Patterns Increase PE participation Increase recreational physical activity Decrease television viewing Dietary Factors Decrease sweetened beverages Familial & Psychosocial Influences Improve limit-setting Avoid using food as reward Parental modeling of healthy behaviors Position Paper - Prevention of Childhood Overweight What Should Be Done? Center for Weight and Health - U.C. Berkeley 10/02 Spectrum of Prevention: Health behavior change model       Level 1: Strengthening individual knowledge and skills Level 2: Promoting community education Level 3: Educating service providers Level 4: Fostering coalitions and networks Level 5: Changing organizational practice Level 6: Influencing policy and legislation Spectrum of Prevention The most effective and sustainable PH intervention approaches of the past 2 decades are the more ―upstream‖ ones (structural/environmental vs. individuallevel), involving social norm change:  Tobacco control  Alcohol consumption and driving  Breastfeeding Is fat the next tobacco? SB 19 – Escutia – Pupil Health Chaptered - This bill establishes, as of 1/1/04, various prohibitions on the sale of beverages in schools and places nutritional standards on the type of foods that may be sold to pupils. 10/01 Board of LA school district votes to ban soda sales in schools. 8/02 McDonald's reported it’s first-ever quarterly loss. 1/03 SF school board approves ban on sale of ‘unhealthy snacks' in schools. 1/03 CA State Sen. Torlakson to introduce 3 bills to encourage healthy habits in schools. 2/03 Effective Physical Activity Promotion Physical environmental change is not enough! Social norms and values must also be addressed. Unlike hunger, there’s no inherent drive for PA—we must make it easier to do it than not to do it!! Effective Physical Activity Promotion Cultivation of role models in PA promotion ideally to create enjoyable experience:  Exercise skills demonstration  Engaging, interactive leadership style  Fostering interactions between audience members  Modeling behaviors & encouraging others  Relevant characteristics, in addition to ethnicity and gender, include weight status, fitness level, agility, and age; aspirational & inspirational role models NEEDED! Spectrum of Prevention th level) (4 Level of Prevention Definition of Level Bringing together groups and individuals for broader goals and greater impact Examples of Obesity Prev. Efforts Local project coalitions & advis. comm. Healthy Cities coalitions Governor’s Councils on Physical Fit. & Sports Fostering coalitions and networks REACH 2010 Initiative    CDC-funded Racial & Ethnic Approaches to Community Health mechanism to address ethnic health disparities 24 implementation phase projects nationally Community Health Councils, Inc., lead agency for African Americans Building a Legacy of Health,  collaborates with 220 local agencies, CBOs, govt entities, universities, and businesses on various projects, to sponsor seminars for providers, patient education workshops, office staff training Community-based participatory research model African Americans Building a Legacy of Health: Process evaluation Intervention: Multi-component, centered around modeling the behaviors promoted (―walking the talk‖)–(1) incorporation of fitness breaks into meetings, events and other gatherings, (2) provision of wellness training focused on changing the norms of organizations to incorporate physical activity into their regular conduct of business, (3) provision of a personal training to CBO leaders, (4) development of a small grants program to map & enhance PA opportunities; African Americans Building a Legacy of Health: Process evaluation Measures: Level of organizational support for physical activity integration assessed by level of commitment represented in interventions selected; Results: Nearly half of the >200 participating organizations demonstrated active support for physical activity integration, with >25% committed at the highest level of support; African Americans Building a Legacy of Health: Process evaluation Conclusions: Broad capacity and support for organizational integration of physical activity was demonstrated, with level of commitment varying by organization type. Similar to the successful evolution of tobacco control, organizational policies that incorporate physical activity into the normal conduct of business should be implemented and evaluated. Spectrum of Prevention th level) (5 Level of Prevention Definition of Level Examples of Obesity Prev. Efforts Protocols for MD assessment, sliding fees, counseling & referral Worksite policies (movement breaks, vending, refreshments) School PE content & delivery Changing organizational practice & policy Adopting regulations and shaping norms to improve health California Fit WIC Staff Wellness Training AIMS:  To provide skills and tools to influence workplace organizational practices and cultural norms to promote physical activity & healthy eating among staff  To provide skills and tools to influence staff to promote physical activity & healthy eating among WIC clients/families California Fit WIC Staff Wellness Training Training sessions included:  Engagement around ubiquitous nature of the problem (―toxic‖ environment surrounding us)  Skills training in workplace practice change (e.g., movement breaks, walking mtgs, leading co-workers to stairs vs. elev., healthy refreshments & identifying practical strategies to integrate PA (parking farther away, walking around children’s play area, carrying a basket vs. pushing a grocery cart)  Empowerment thru provision of tools, e.g., California Fit WIC Staff Wellness Training Even the longest journey begins with a single step. Newer Pyramid Ideas How to read a food label % Daily value: All you need to know < 5% Fat = Low Fat > 20% - Good source of nutrient WIC Staff Wellness Training California Fit WIC Staff Wellness Training Significant findings:  Increased perceived workplace support for staff PA (96 vs 58%, p=.002) and healthy food choices (85 vs 28%, p=.001)  Change in types of foods served during mtgs (72 vs 24%, p=.002) & PA priority in workplace (96 vs 71%, p<.02)  Increased self-reported counseling behaviors with WIC parents promoting physical activity (64 vs 35%, p<.05) & sensitivity in handling weight-related issues (92 vs 58%, p<.01) Fuel Up/Lift Off! LA   Social marketing campaign to create organizational practice change & social support for healthy eating and active living, raising the visibility of obesity epidemic Two main components: 1. In-person and media-facilitated exercise demonstrations in meetings/gatherings 2. CBO staff training sessions (Steppin’ Up to Better Health) LAC Fitness & Wellness Study: design Randomized, controlled, post-test only, intervention trial testing the effects of incorporation of 10-min exercise breaks into staff mtgs & training seminars lasting > 1 hr  1o outcome measures: (1) satisfaction with fitness level; (2) self-reported mood/well-being  Fuel Up/Lift Off! LA Video/audiotape excerpt: movement break (Lift Off) demonstration LAC Fitness & Wellness Study: Results Full study implemented in 26 meetings with 449 individuals, 11 interv & 15 ctl  Sample: 73.6% female; x=41 yrs; 35% Latino, 20% AA, 20% W, 17% API; 64% rel. sedentary; 57% overweight  Stage of change distrib: I-4.6%; II21.9%; III-36.2%; IV-12.8%; V-24.6%  LAC Fitness & Wellness Study: Results (cont.) Among relatively sedentary respondents:  Intervention participants’ satisfaction with fitness levels more highly correlated with PA stage of change (r=.59) than controls (r=.38, z=-2.32, p=.02)  Intervention participants’ objectively categorized PA levels tended to be more correlated with PA stage of change (r=.42) compared with controls (r=.28, z=1.41, p=.16) LAC Fitness & Wellness Study: Results (cont.) Of those intervention participants responding to the question:  80% indicated that participating in a movement break made them feel better about their jobs  Mirrors data from worksite PA prom. studies demonstrating improved employee productivity & morale LAC Fitness & Wellness Study: Conclusions    Captive sedentary, overweight audiences may be engaged in brief bouts of PA as a part of the workday, regardless of stage of change PA experience decreases sedentary individuals satisfaction with their suboptimal fitness levels and, perhaps, their overestimation of their own PA participation Organizational practices that incorporate PA into the normal conduct of business should be implemented and evaluated Community Steps to Minority Youth Fitness NICHHD-funded R01, part of NIH Innovative Approaches to Prevention of Obesity Initiative METHODS Sixth-grade students from a randomly assigned southern Los Angeles middle school were recruited for a 10-week in-school nutrition/ physical activity program replacing standard PE classes. METHODS Sixth-grade students from a second middle school, matched for ethnic and SES status, were recruited as a control group. They participated in the standard PE curriculum. CHALLENGES 6th grade enrollment in intervention site increased by 50% (from 600 to 900 students) between conduct of pilot and full study implementation—extending t devoted to roll call & clothes change  Intervention site was named one of four under-performing schools threatened with state administrative take-over  RESULTS    Baseline sample (n=226) Gender: Female=124 (54.9%) Ethnicity: Latino/Hispanic=122 (54%) African American =88 (38.9%) Caucasian = 0 Asian American = 2 (0.9%) Native American = 2 (0.9%) Biracial = 9 (4.0%) Other = 3 (1.3%) RESULTS   Using revised CDC guidelines for BMI classification, 52.8% (n=105) were normal weight, 15.6% (n=31) were at risk for becoming overweight, and 31.7% (n=63) were overweight. Serum cholesterol levels were elevated among 46.4% of the students. Preliminary Intervention RESULTS 9 8 7 6 5 4 3 2 1 0 Intrv-Bas Intrv-12m Contr-Bas Contr-12m Fruit Vege HF Pref Score CONCLUSIONS    Pre-adolescent ethnic minority students already manifest health complications associated with poor eating habits & fitness, including obesity, elev. BP & hyperlipidemia. Elevated systolic BP, but not Chl, shows positive linear correlation with BMI. Age-related declines in fruit, juice and vegetable consumption, but not weight or fitness, may be decreased by low-intensity, intervention in low-resource school environment. Community “Cost-Sharing” 1. Leveraging funding agency role to: *mandate healthy/fit workplace practices, with added resource allocation (e.g., 5%) *ensure that a majority of intervention models include a structural (environmental) change component and are developed and tested in ethnically diverse, non-affluent settings; 2. Changing internal organizational culture (social norms) to create healthy/fit foundation workplaces (―Walk the Talk‖) Community “Cost-Sharing” (cont.) 3. Modeling recommended behaviors in regularly scheduled public (televised) & private meetings and events, e.g., staff meetings, school board hearings, city council meetings, state legislative sessions, gospel choir rehearsals, adult evening classes, pot lucks, middle school home room periods, press conferences Example: Culver City provides 60 min./wk (20 min. on 3 days) of work time for PA breaks; Example: REACH project-- >100 CBOs actively Gov’t “Cost-Sharing” (cont.) VISION: Employees feel the same sense of entitlement to exercise breaks on ―company time‖ as breaks for smoking or coffee MODEL: Smokefree workplace practices, often mandated by funding agencies, pre-dated legislative policy smokefree workplace mandates Community “Cost-Sharing” (cont.) BOTTOM LINE: ―Actively‖ engaging decision-makers, opinion leaders, service providers & gatekeepers in healthy lifestyle change is critical to their prioritizing these issues: (a) in creating the social momentum/political will for legislative policy change; and (b) in their professional and personal governance of youth activities. LAST WORD: Currency I gave Akil The spot I earned In a pick-up game You know, b-ball To a kid That's like money Currency Currency (cont.) I gave Akil A serious stroke Told him He's the brightest Kid I've met To a kid That's like money Currency Currency (cont.) I gave Robyn A heartfelt compliment Told her She's the best Student I've known To a kid That's like money Currency Currency (cont.) Akil gave me An ego boost Told some other folk I taught him to play You know, b-ball To me That's like money Currency Currency (cont.) Robyn gave me The ultimate gift Told my aunts She wanted to be A model/doctor Just like "Aunt Toni" To me That's like money Currency Currency (cont.) All that currency Exchanged between us And nobody Spent a dime!