Cmty-Level Obesity Interventions

SEVERITY

US corn subsidies

Beverage companies spending $3.2B annually on marketing, $0.5B to kids 2-17 years (FTC, 2008)

• $7B in tax money subsidies
• 56% of US adults’ daily calories come from subsidized foods
• 37% higher risk of being obese of those in highest quartile of subsidized food consumption compared to lowest quartile (Siegel, 2016)

End of AAFP-Coca Cola alliance as a result of membership pressure and resolutions

1973

2012

2015

sugary drinks

2014

2006

2009

NOW

Consumption declining in US, but increasing in other countries of heavy marketing

Coca Cola selfishly gives $600k to AAFP for FamilyDoctor.org site

Health consequences of sugary drinks

Increased risk of developing:

• obesity
• for each additional 12-ounce soda children consumed each day, the odds of becoming obese increased by 60% during 1½ years of follow-up (Ludwig, 2001)
• heart disease
• men who consumed one can of a sugary beverage per day had a 20% higher risk of having a heart attack or dying from a heart attack than men who rarely consumed sugary drinks (de Koning, 2012)
• diabetes
• people who consume sugary drinks regularly—1 to 2 cans a day or more—have a 26% greater risk of developing type 2 diabetes than people who rarely have such drinks (Malik, 2010)

Health consequences of diet drinks

Increased risk of developing:

• tooth enamel erosion
• higher phosphoric acid levels in diet drinks (Reynolds, 2015)
• stroke & dementia (Pase, 2017)
• for those who drank 1-6 diet sodas per week (compared to zero per week):
• HR 2.96 for developing stroke
• HR 2.89 for developing Alzheimer's disease
• likely due to:
• sodium and caffeine content and asssociated hypertension
• artificial sweeteners altering gut microbiota (Suez, 2014)

OPTIONS

Eating

Grocery store tours

Cooking classes

Cooking Matters Courses

Two hour courses, weekly for six weeks taught by a volunteer chef and nutrition educator. Lessons cover meal prep, grocery shopping, food budgeting and nutrition. Participants practice fundamental food skills, including proper knife techniques, reading ingredient labels, cutting up a whole chicken, and making a healthy meal for a family of four on a $10 budget. Adults and teens take home a bag of groceries after each class so they can practice the recipes taught that day.

6 mos after course, participants are cooking healthier meals at home.

Cooking Matters at the Store

1.5 hour-tour, participants learn:

• Reading food labels
• Comparing unit prices
• Finding whole grain foods
• Identifying three ways to purchase produce

Ends in the $10 Challenge, an activity where participants use the skills they've just learned to buy a healthy meal for a family of four, for under $10.

58% of graduates intend to compare food labels

Farmers market tokens

Salad bars to schools

Most states allow SNAP monies to be used to purchase tokens (some give "double bucks")

70% of participants indicate increase in fruits and vegetables purchases (Bowling, 2016)

Nearly 2.5 million children served at nearly 5,000 schools.

Requests for salad bar units ($2625 each unit) fulfilled through grassroots fundraising in the school community and through funds raised by partners from corporate and foundation sources.

There was a significant increase in frequency (2.97-4.09) of fruits & vegetables consumed among the children studied (Slusser, 2007)

Exercise

Park Rx

YMCA: Diabetes Prevention Program

Dr Robert Zarr at Unity Health Care in DC prescribes walks in the parks for his pediatric patients: (1) to help create a healthier, happier society, and (2) to preserve and create more natural places through our next generation of environmental stewards, conservationists, and activists.

200 Y's in the US target prediabetics with goals of: (1) losing 5–7% of body weight, and (2) gradually increasing physical activity to 150 minutes per week.

Yielded 2-fold greater weight loss (mean, 3.0% [95% CI, 1.9% to 4.1%]) than less structured approaches (Balk, 2015)

Multifactorial

Systematic review and meta-analysis:

What childhood obesity prevention programs work? (Wang, 2015):

SOE was moderate that community-based, diet–physical activity combined interventions that include a school component prevent obesity.

SOE was insufficient for interventions implemented in the community alone or with support from other settings.

Multifactorial

Systematic review and meta-analysis: Whole of community interventions to prevent excessive population weight gain (Wolfenden, 2014):

Seven of eight studies showed improvement in at least one measure of adiposity.

Interventions included: walking groups, school food gardens, provision of water bottles and activity equipment, provision of training for school staff, poster displays, community events, and student aerobics clubs.

Multifactorial

Cochrane review: Interventions for preventing obesity in children

(Waters, 2011):

Out of 55 programs evaluated, BMI showed a 0.15 kg/m2 reduction which would correspond to a small but clinically important shift in population BMI if sustained over several years. Programs have not caused adverse outcomes or increased health inequalities.

• Curriculum on healthy eating, physical activity and body image integrated into regular curriculum
• More sessions for physical activity and the development of fundamental movement skills throughout the school week
• Improved nutritional quality of foods made available to students
• Creating an environment and culture that support children eating nutritious foods and being active throughout each day
• Providing support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities)
• Engaging with parents to support activities in the home setting to encourage children to be more active, eat more nutritious foods and spend less time in screen-based activities

Multifactorial

National Academy of Science:

Accelerating Progress in Obesity Prevention (Glickman, 2012):

• zoning to limit fast-food establishments
• facilitating the situating of supermarkets in underserved areas
• increasing the availability of farmers’ markets
• creating and supporting community gardens
• supporting safe routes to school
• creating and maintaining a walking school bus
• increasing the number of bike paths and parks
• enhancing walking infrastructure

sugary drink tax

sugary drink

warning labels

healthy vending choices

Steps to Implement

References

• Bailey LC, et al. Association of antibiotics in infancy with early childhood obesity. JAMA Pediatr. 2014 Nov;168(11):1063-9.
• BalkEMEarleyARamanGAvendanoEAPittasAGRemingtonPLCombined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task Force.Ann Intern Med201516343751
• Bowling AB, et al. Healthy Foods, Healthy Families: combining incentives and exposure interventions at urban farmers' markets to improve nutrition among recipients of US federal food assistance. Health Promot Perspect. 2016 Mar 31;6(1):10-6.
• Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ. 2012;31:219-30.
• Colchero MA, et al. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ. 2016; 352: h6704.
• de Koning L, Malik VS, Kellogg MD, Rimm EB, Willett WC, Hu FB. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation. 2012;125:1735-41, S1.
• Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics. 2006;117:673-80.
• US Federal Trade Commission. Marketing Food to Children and Adolescents: A Review of Industry Expenditures, Activities, and Self-Regulation. Washington, DC: US Federal Trade Commission; 2008.
• Fryar CD, Carroll MD, and Ogden CL. Prevalence of Overweight and Obesity Among Children and Adolescents Aged 2–19 Years: United States, 1963–1965 Through 2013–2014. Health E-Stats July 2016. Available at: http://www.cdc.gov/nchs/data/hestat/obesity_child_13_14/obesity_child_13_14.htm
• Glickman D, et al. Accelerating Progress in Obesity Prevention SOLVING THE WEIGHT OF THE NATION. National Academy of Science, 2012, New York, NY.
• Harsch IA, et al. Leptin and ghrelin levels in patients with obstructive sleep apnoea: effect of CPAP treatment. Eur Respir J. 2003 Aug;22(2):251-7.
• Joosten SA, et al. Impact of Weight Loss Management in OSA. Chest. 2017 Feb 6. [Epub ahead of print]
• Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505-8.
• Malik VS, Popkin BM, Bray GA, Despres JP, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33:2477-83.
• McCarthy M. Soda tax brings sharp fall in sugary drink consumption in Californian city. BMJ 2016;355:i5940
• Ogden CL, Carroll MD, Lawman HG, et al. Trends in Obesity Prevalence Among Children and Adolescents in the United States, 1988-1994 Through 2013-2014. JAMA 2016; 315:2292.
• Pase MP, et al. Sugar- and Artificially Sweetened Beverages and the Risks of Incident Stroke and Dementia. Stroke. 2017;48:1139-1146
• Reynolds E, et al. “The potential of sugar-free beverages, sugar-free confectionary and sports drink to cause dental erosion.” Briefing paper, Oral Health CRC, University of Melbourne, 2015
• Schroeder BO, Backhed F. Signals from the gut microbiota to distant organs in physiology and disease. Nature Medicine 2016, 22, 1079–1089.
• Siegel KR, et al. Association of Higher Consumption of Foods Derived From Subsidized Commodities With Adverse Cardiometabolic Risk Among US Adults. JAMA Intern Med. 2016;176(8):1124-1132.
• Slusser WM, et al. A school salad bar increases frequency of fruit and vegetable consumption among children living in low-income households. Public Health Nutr. 2007 Dec;10(12):1490-6.
• Suez J, Korem T, Zeevi D, Zilberman-Schapira G, Thaiss CA, Maza O, et al. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature. 2014;514:181–186. doi: 10.1038/nature13793
• Tate DF, Turner-McGrievy G, Lyons E, et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr. 2012;95:555-63.
• Wang Y, et al. What childhood obesity prevention programmes work? A systematic review and meta-analysis. Obes Rev. 2015 Jul; 16(7): 547–565.
• Waters E, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD001871
• Wolfenden L, et al. A systematic review and meta-analysis of whole of community interventions to prevent excessive population weight gain. Preventive Medicine, 2014-05-01, Volume 62, Pages 193-200
• Yan J, et al. The association between breastfeeding and childhood obesity: a meta-analysis. BMC Public Health. 2014; 14: 1267.

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