The Culture, Politics and Economics of Our Obesogenic Society

1
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

2
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 criticalsociety has
  key role in sharing, with individuals, the high
  costs of healthy lifestyle change/maint.

3
Obesity Trends Among U.S. AdultsBRFSS, 1985
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
4
Obesity Trends Among U.S. AdultsBRFSS, 1986
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
5
Obesity Trends Among U.S. AdultsBRFSS, 1987
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
6
Obesity Trends Among U.S. AdultsBRFSS, 1988
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
7
Obesity Trends Among U.S. AdultsBRFSS, 1989
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
8
Obesity Trends Among U.S. AdultsBRFSS, 1990
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
9
Obesity Trends Among U.S. AdultsBRFSS, 1991
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
10
Obesity Trends Among U.S. AdultsBRFSS, 1992
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
11
Obesity Trends Among U.S. AdultsBRFSS, 1993
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
12
Obesity Trends Among U.S. AdultsBRFSS, 1994
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
13
Obesity Trends Among U.S. AdultsBRFSS, 1995
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
14
Obesity Trends Among U.S. AdultsBRFSS, 1996
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
15
Obesity Trends Among U.S. AdultsBRFSS, 1997
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
16
Obesity Trends Among U.S. AdultsBRFSS, 1998
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
17
Obesity Trends Among U.S. AdultsBRFSS, 1999
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
18
Obesity Trends Among U.S. AdultsBRFSS, 2000
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
19
Obesity Trends Among U.S. AdultsBRFSS, 2001
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
20
Prevalence of Overweight Among U.S. Children and
Adolescents Ages 6-19 Years
SOURCE CDC/NCHS, NHES and NHANES
21
Center for Public Health Advocacy An Epidemic of
Unfit and Overweight Children http//www.publichea
lthadvocacy.org/
REGIONAL HEALTH EDUCATION
22
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

23
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.

24
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

25
Overweight Rates, L.A. County Adults
26
Physical Activity Levels, L.A. County Adults,
1999
27
Weight Status by Ethnicity Gender, LA County
Adults
28
Weight Status by Ethnicity Gender, LA County
Adults (cont.)
29
Weight Status by Sexual Orientation, LA County
Adult Women
30
Self-Perceived Overweight by Ethnicity Gender,
LA County Adults
31
Influence of Self-Perceived Weight Status on
PA, 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
  (OR1.40, CI 1.19, 1.64)
• Yancey, Wold et al., in preparation, 2003

32
A small behavior change over time can
create/prevent some weight problems.
33
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)

34
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)

35
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.

36
5th Grade SAT9 percentile and Fitness
Performance
SAT 9 Percentile
Number of Fitness Standards Achieved
37
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
38
Spectrum of PreventionHealth 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

39
Spectrum of Prevention

• The most effective and sustainable PH
  intervention approaches of the past 2 decades are
  the more upstream ones (structural/environmental
  vs. individual-level), involving social norm
  change
• Tobacco control
• Alcohol consumption and driving
• Breastfeeding

40
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 its 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
Is fat the next tobacco?
41
Effective Physical Activity Promotion

• Physical environmental change is not enough!
  Social norms and values must also be addressed.
  Unlike hunger, theres no inherent drive for
  PAwe must make it easier to do it than not to do
  it!!

42
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!

43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
Spectrum of Prevention(4th level)
48
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

49
African Americans Building a Legacy of
HealthProcess 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

50
African Americans Building a Legacy of
HealthProcess evaluation

• Measures Level of organizational support for
  physical activity integration assessed by level
  of commitment represented in interventions
  selected Results Nearly half of the gt200
  participating organizations demonstrated active
  support for physical activity integration, with
  gt25 committed at the highest level of support

51
African Americans Building a Legacy of
HealthProcess 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.

52
Spectrum of Prevention(5th level)
53
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

54
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 childrens play area, carrying a basket
  vs. pushing a grocery cart)
• Empowerment thru provision of tools, e.g.,
  videos, audiotapes, exercise bands, pedom.

55
California Fit WIC Staff Wellness Training
Even the longest journey begins with a single
step.
56
Newer Pyramid Ideas
57
How to read a food label
58
Daily value All you need to know
lt 5 Fat Low Fat gt 20 - Good source of
nutrient
59
WIC Staff Wellness Training
60
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, plt.02)
• Increased self-reported counseling behaviors with
  WIC parents promoting physical activity (64 vs
  35, plt.05) sensitivity in handling
  weight-related issues (92 vs 58, plt.01)
• Crawford, Gosliner, Strode et al., in
  preparation, 2003

61
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)

62
(No Transcript)
63
(No Transcript)
64
LAC Fitness Wellness Studydesign

• Randomized, controlled, post-test only,
  intervention trial testing the effects of
  incorporation of 10-min exercise breaks into
  staff mtgs training seminars lasting gt 1 hr
• 1o outcome measures (1) satisfaction with
  fitness level (2) self-reported mood/well-being

65
Fuel Up/Lift Off! LA

• Video/audiotape excerpt movement break (Lift
  Off) demonstration

66
LAC Fitness Wellness StudyResults

• Full study implemented in 26 meetings with 449
  individuals, 11 interv 15 ctl
• Sample 73.6 female x41 yrs 35 Latino, 20
  AA, 20 W, 17 API 64 rel. sedentary 57
  overweight
• Stage of change distrib I-4.6 II-21.9
  III-36.2 IV-12.8 V-24.6

67
LAC Fitness Wellness StudyResults (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, z1.41, p.16)

68
LAC Fitness Wellness StudyResults (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

69
LAC Fitness Wellness StudyConclusions

• 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 over-estimation of their own
  PA participation
• Organizational practices that incorporate PA into
  the normal conduct of business should be
  implemented and evaluated

70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
Community Steps to Minority Youth Fitness

• NICHHD-funded R01, part of NIH Innovative
  Approaches to Prevention of Obesity Initiative

74
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.

75
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.

76
CHALLENGES

• 6th grade enrollment in intervention site
  increased by 50 (from 600 to 900 students)
  between conduct of pilot and full study
  implementationextending t devoted to roll call
  clothes change
• Intervention site was named one of four
  under-performing schools threatened with state
  administrative take-over

77
RESULTS

• Baseline sample (n226)
• Gender Female124 (54.9)
• Ethnicity
• Latino/Hispanic122 (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)

78
RESULTS

• Using revised CDC guidelines for BMI
  classification, 52.8 (n105) were normal weight,
  15.6 (n31) were at risk for becoming
  overweight, and 31.7 (n63) were overweight.
• Serum cholesterol levels were elevated among
  46.4 of the students.

79
Preliminary InterventionRESULTS
80
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.

81
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)

82
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-- gt100 CBOs actively
  incorporated PA breaks into mtgs/events

83
Govt 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

84
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.

85
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

86
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

87
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

88
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

89
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

90
Currency (cont.)

• All that currency
• Exchanged between us
• And nobody
• Spent a dime!