Evaluating State Public Health Nutrition Programs

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Evaluating State Public Health Nutrition Programs

• Marilyn Sitaker, MPH,
• Epidemiologist
• Cardiovascular Disease, Diabetes, Nutrition and
  Physical Activity Section,
• Washington State Department of Health

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Learning Objectives for this Lecture

•  Identify sources of data for nutrition and
  physical activity surveillance used for
  state-level planning and monitoring.
• Describe the strengths and weaknesses of existing
  data and data systems for state level practice 
• Analyze the application and politics of the use
  of data at the state level for reports, policy
  development, and performance measures.
• Apply these understandings to state level
  evaluation of the Washington State Plan for
  Nutrition and Physical Activity

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Washington State Plan for Physical Activity and
Nutrition

• Purpose
• 1.  Slow the increase in the proportion of
  adults who are obese
• 2.  Reduce rates of chronic disease
• 3.  Improve the quality of life
• Overarching goals
•         Increase the proportion of adults and
  children who have diets that reflect the Dietary
  Guidelines for Americans.
•         Increase the proportion of adults and
  children who meet the physical activity
  recommendations.

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Objectives of the State Plan

• Physical activity objectives
• 1. Increase the number of people who have access
  to free or low cost recreational opportunities
  for physical activity
• 2. Increase the number of physical activity
  opportunities available to children
• 3. Increase the number of active community
  environments

• Nutrition objectives
• 1. Increase access to health promoting foods
• 2. Reduce hunger and food insecurity
• 3. Increase the proportion of mothers who
  breastfeed their infants and toddlers

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Nutrition Sub-objectives

• Increase access to health promoting foods
• Increase the consumption of vegetables and
  fruits.
• Assure that worksites provide healthful foods and
  beverages
• Ensure that K-12 schools provide healthful foods
  and beverages
• Reduce hunger and food insecurity
• Provide adequate support for nutrition and food
  programs
• Improve access to nutrition programs
• Increase the proportion of mothers who breastfeed
  their infants and toddlers
• Assure that health care settings, child care
  facilities, and worksite environments are
  breastfeeding-friendly.

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Physical Activity Sub-objectives

• Increase the of people who have access to free
  or low cost recreational opportunities for
  physical activity
• Adequate funding for state and local recreational
  sites and facilities.
• Model policies to increase access to public
  facilities for PA
• Increase the number of worksites with policies
  that facilitate opportunities for PA
• Increase the of physical activity opportunities
  available to children
• School based curricula and policies for quality,
  daily physical education
• Policies to provide K-12 students with
  opportunities for PA outside of P.E. Class
• Replace sedentary behaviors, such as watching
  television, with physical activity
• Increase the of active community environments
  in Washington State
• Use urban planning approaches zoning and land
  use.
• Change transportation policy to promote
  non-motorized transportation
• Enhance safety and perceived safety to improve
  walkability and bikeability

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Levels of Influence in the Social-Ecological Model
Structures, Policies, Systems Local, state,
federal policies and laws to regulate/support
healthy actions
Institutions Rules, regulations, policies
informal structures
Community Social Networks, Norms, Standards
Interpersonal Family, peers, social networks,
associations
Individual Knowledge, attitudes, beliefs
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What do we mean by Environment?
Sociocultural Value that schools place of
physical education teachers serve as role models
Physical Safe walking paths, home gardens, fresh
produce in local markets
Environment
Policies Active transport given priority. Zoning
for walking or cycling protecting open spaces
Economic Monetary incentives/ disincentives in
form of taxes, pricing policies subsidies
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Evaluation of the State Plan

• Statewide Assessment 
• Level 1 Assess Progress on the Plan Objectives
• Level 2. Monitor Environmental and Policy
  Efforts Related to Nutrition and Physical
  Activity
• Level 3 Ongoing monitoring of body mass index,
  nutritional intake and status, physical activity
  levels, knowledge and perception, and prevalence
  of chronic disease related to nutrition and
  physical activity

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Evaluation of the State Plan

• Statewide Assessment 
• Level 1 Assess Progress on the Plan Objectives
• Increase access to health promoting foods
• Reduce hunger and food insecurity
• Increase the percent of mothers who breastfeed
  their infants and toddlers
• Increase the number of persons in communities who
  have access to free and low cost recreational
  opportunities for physical activity
• Increase the number of physical activity
  opportunities specifically available to children
• Increase the number of active community
  environments

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Examples of Potential Strategies to Evaluate
Level 1

• Reduce Hunger and Food Insecurity
• Use Current Population Survey Food Security
  Supplement Analyze results for Washington State
  disseminate to stakeholders
• Increase the percent of mothers who breastfeed
  their infants and toddlers
• Use PRAMS to determine breastfeeding initiation
  rates rates at 1-2 months post partum
• Increase the number of persons in communities
  who have access to free and low cost recreational
  opportunities for physical activity
• Draft, pilot test implement new BRFSS questions
  on access to low cost recreational opportunities
  analyze report to stakeholders

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Evaluation of the State Plan

• Statewide Assessment 
• Level 2. Monitor Environmental and Policy
  Efforts Related to Nutrition and Physical
  Activity
• School Health Policy Survey CDC sponsored survey
• Worksite Policy Survey DOH, STEPS/CDNPA survey
• Healthcare Quality CDEMS and DEMS databases
• Community Survey of Municipal Policies GIS data
  to ascertain Food Deserts under development

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Worksite Policy Survey (nutrition module)

• Nutrition
• Now Im going to ask about things that can
  encourage healthy eating.
• 7. Does your worksite have a place where
  employees can refrigerate food?
• 1.) Yes 2.) No 3. Dont Know 4.)
  Refused
• 8. Does your worksite have any policies or
  guidelines encouraging healthy foods to be served
  at staff meetings, company-sponsored events or in
  customer/client areas?
• 1.) Yes 2.) No 3. Dont Know 4.)
  Refused
• 9. Not including food brought to work, is food
  available to employees during working hours in a
  cafeteria, snack bar or coffee shop, and/or
  vending machines?
• 1.) Yes 2.) No 3. Dont Know 4.)
  Refused
• 10. (If yes to question 9) Which food options
  are available at your worksiteeither in a
  cafeteria, snack bar or coffee shop, and/or
  vending machines? (ANSWER YES OR NO TO EACH ITEM
  IN THE LIST)
• 1.) Lowfat milk 2.) Water/flavored water 3.)
  100 fruit juice 4.) Fresh fruit or vegetables
  5.) Low fat snacks (e.g., pretzels, chex mix, or
  granola bars)
• 12. Does your worksite provide labels to identify
  the healthier food choices available at the
  worksite (such as labels added by cafeteria staff
  or health director, NOT information on a product
  label such as lite, low fat, or sugar free.
• 1.) Yes 2.) No 3. Dont Know 4.)
  Refused

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Evaluation of the State Plan

• Statewide Assessment 
• Level 3 Ongoing monitoring of body mass index,
  nutritional intake and status, physical activity
  levels, knowledge and perception, and prevalence
  of chronic disease related to nutrition and
  physical activity
• Washington Vital Records System (death
  certificates)
• Washington Behavioral Risk Factor Surveillance
  System

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Data Sources Death Certificate System

• Annual information on all deaths that occur in
  Washington, and of Washington residents who die
  in other states
• Estimated to be 99 complete.
• Cause of death determined by the attending
  physician or the coroner/ medical examiner.
• Instruction manuals are provided to physicians,
  coroners, and medical examiners, as well as local
  health jurisdictions and others involved in
  completing and managing death certificates.
• Causes of death are coded according to the
  International Classification of Disease, World
  Health Organization, Ninth Revision (ICD-9) for
  1979-1998 Tenth revision (ICD-10) for 1999 and
  later.

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Data Sources State of Washington Behavioral Risk
Factor Surveillance System (BRFSS)

• Telephone health survey of chronic diseases,
  injuries and their risk factors, coordinated by
  the Center for Disease Control and Prevention
  (CDC), conducted annually in 50 states since 1986
  
• Self-reported information collected from a random
  sample of adults living in households with
  telephones.
• 2003 data includes 18,000 records to facilitate
  county level estimation 400 interview conducted
  in Spanish.

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BRFSS Topics

• Health status, including general, physical, and
  mental heath, as well as activity lost because of
  health conditions.
• Access to health care, as measured by having
  health insurance, being able to see a doctor
  because of cost, and time since last routine
  checkup.
• Awareness of selected medical conditions 
  hypertension, diabetes, and high cholesterol.
• Nutrition and weight control, including eating of
  fruits and vegetables and experiencing hunger.
• Injury control, including use of seatbelts by
  respondents and children in their household.
• Tobacco use and alcohol consumption.
• Social and demographic characteristics, including
  gender, age, race/ethnicity, marital status,
  education attainment, employment, household
  income, weight and height.

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For example the nutrition module asks how often
certain foods are eaten fruit juice, fruit,
green salad potatoes (other than french fries,
fried potatoes or chips) and carrots. A summary
index measure is derived from these
questions Note how often an item is eaten is not
the same as number of servings
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CVD Risk Factors Among Washington Adults, 2001 or
2002
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Data Sources State of Washington Healthy Youth
Survey (BRFSS)

• Sponsored by OSPI, DOH, DSHS-DASA, and Office of
  Community Development
• Health pencil-and-paper survey combining
  questions from the CDCs Youth Behavioral Risk
  Survey (YBRS) and the Monitoring the Future
  survey
• Representative sample of schools within a school
  district
• Grades 6, 8, 10 and 12 answered questions about
  safety and violence, physical activity and diet,
  alcohol, tobacco and other drug use, and related
  risk and protective factors. Administered in the
  Fall of 2002 2004.

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Questions about Physical Activity on the HYS
Meeting recommended levels of vigorous daily
activity How many of the past 7 days did you
exercise or participate in physical activity for
at least 20 minutes that made you sweat and
breathe hard, such as basketball, soccer,
running, swimming laps, fast bicycling, fast
dancing, or similar aerobic activities?
  Meeting recommended levels of moderate daily
activity How many of the past 7 days did you do
physical activity for at least 30 minutes that
did not make you sweat and breathe hard, such as
fast walking, slow bicycling, skating, pushing a
lawn mower, or mopping floors?   Strength
Training How many of the past 7 days did you do
exercises to strengthen or tone your muscles,
such as push-ups, sit-ups, or weight lifting?
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Number of (Non-Diet) Sodas Yesterday
2, Grade 10 by Sex
P lt 0.05
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Overweight and 2 Sodas Yesterday

Percent

P lt 0.05
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2 or more (non-diet) sodas yesterday and other
nutrition-related questions, grade 10 example





Percent
? 5 lt5 yes no yes
no yes no daily times
usually food insecure
inappropriate fruit veggies family dinner
dieting (girls)
P lt 0.05
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Pregnancy Risk Assessment Monitoring System

• Joint research project of the Washington DOH
  CDC since 1996
• Mail/phone survey of 2,000 new mothers,
  randomly sampled (by race/ethnicity) from birth
  certificate records, at 2-6 months after
  delivery.
• Provides data for the period before, during and
  shortly after their pregnancy
• Topics include prenatal care received, health
  behaviors during pregnancy, barriers to
  receiving prenatal care
• Also consumer ideas about pregnancy and early
  infant care
• And, finally intendedness of pregnancy, use of
  alcohol and tobacco, baby's sleeping position,
  percent of women breastfeeding, social support,
  and battering during pregnancy.

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