Recommended Community Strategies and Measurements to Prevent Obesity in the United States

Recommended Community Strategies and Measurements to Prevent Obesity in the United States

Reported by
Laura Kettel Khan, PhD1
Kathleen Sobush, MS, MPH2
Dana Keener, PhD3
Kenneth Goodman, MA3
Amy Lowry, MPA2
Jakub Kakietek, MPH3
Susan Zaro, MPH3

1Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC

2CDC Foundation, Atlanta, Georgia

3ICF Macro, Atlanta, Georgia

Summary
Approximately two thirds of U.S. adults and one fifth of U.S. children are obese or overweight. During 1980--2004, obesity prevalence among U.S. adults doubled, and recent data indicate an estimated 33% of U.S. adults are overweight (body mass index [BMI] 25.0--29.9), 34% are obese (BMI ≥30.0), including nearly 6% who are extremely obese (BMI ≥40.0). The prevalence of being overweight among children and adolescents increased substantially during 1999--2004, and approximately 17% of U.S. children and adolescents are overweight (defined as at or above the 95% percentile of the sex-specific BMI for age growth charts). Being either obese or overweight increases the risk for many chronic diseases (e.g., heart disease, type 2 diabetes, certain cancers, and stroke). Reversing the U.S. obesity epidemic requires a comprehensive and coordinated approach that uses policy and environmental change to transform communities into places that support and promote healthy lifestyle choices for all U.S. residents. Environmental factors (including lack of access to full-service grocery stores, increasing costs of healthy foods and the lower cost of unhealthy foods, and lack of access to safe places to play and exercise) all contribute to the increase in obesity rates by inhibiting or preventing healthy eating and active living behaviors. Recommended strategies and appropriate measurements are needed to assess the effectiveness of community initiatives to create environments that promote good nutrition and physical activity. To help communities in this effort, CDC initiated the Common Community Measures for Obesity Prevention Project (the Measures Project). The objective of the Measures Project was to identify and recommend a set of strategies and associated measurements that communities and local governments can use to plan and monitor environmental and policy-level changes for obesity prevention. This report describes the expert panel process that was used to identify 24 recommended strategies for obesity prevention and a suggested measurement for each strategy that communities can use to assess performance and track progress over time. The 24 strategies are divided into six categories: 1) strategies to promote the availability of affordable healthy food and beverages), 2) strategies to support healthy food and beverage choices, 3) a strategy to encourage breastfeeding, 4) strategies to encourage physical activity or limit sedentary activity among children and youth, 5) strategies to create safe communities that support physical activity, and 6) a strategy to encourage communities to organize for change.

Corresponding preparer: Laura Kettel Khan, PhD, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC, 4770 Buford Hwy, MS K-24, Atlanta, Georgia 30341-3717. Telephone: 770-488-6018; Fax: 770-488-6500; E-mail: ldk7@cdc.gov.

Introduction
Obesity rates in the U.S. have increased dramatically over the last 30 years, and obesity is now epidemic in the United States. Data for 2003--2004 and 2005--2006 indicated that approximately two thirds of U.S. adults and one fifth of U.S. children were either obese (defined for adults as having a body mass index [BMI] ≥30.0) or overweight (defined for adults as BMI of 25.0--29.9 and for children as at or above the 95% percentile of the sex-specific BMI for age-growth charts) (1,2). Among adults, obesity prevalence doubled during 1980--2004, and recent data indicate that an estimated 33% of U.S. adults are overweight and 34% are obese, including nearly 6% are extremely obese (defined as BMI ≥40.0) (3,4). Being either obese or overweight increases the risk for many chronic diseases (e.g., heart disease, type 2 diabetes, some cancers, and stroke). Although diet and exercise are key determinants of weight, environmental factors beyond the control of individuals (including lack of access to full-service grocery stores, high costs of healthy foods, and lack of access to safe places to play and exercise) contribute to increased obesity rates by reducing the likelihood of healthy eating and active living behaviors (5--7).

States and communities are responding to the obesity epidemic in the United States by working to create environments that support healthy eating and active living (8,9) and by giving public health practitioners and policy makers an opportunity to learn from community-based efforts to prevent obesity. However, the absence of measurements to assess policy and environmental changes at the community level has impeded efforts to assess the implementation of these types of population-level initiatives for preventing obesity. To address this issue, CDC initiated the Common Community Measures for Obesity Prevention Project (the Measures Project). The goal of the Measures Project was to identify and recommend a set of obesity prevention strategies and corresponding suggested measurements that local governments and communities can use to plan, implement, and monitor initiatives to prevent obesity. For the purposes of the Measures Project, a measurement is defined as a single data element that can be collected through an objective assessment of policies or the physical environment and that can be used to quantify the performance of an obesity prevention strategy.. Community was defined as a social entity that can be classified spatially on the basis of where persons live, work, learn, worship, and play (e.g., homes, schools, parks, roads, and neighborhoods).

The Measures Project process was guided by expert opinion and included a systematic review of the published scientific literature, resulting in the adoption of 24 recommended environmental and policy level strategies to prevent obesity. This report presents the first set of comprehensive recommendations published by CDC to promote healthy eating and active living and reduce the prevalence of obesity in the United States. This report describes each of the recommended strategies, summarizes available evidence regarding their effectiveness, and presents a suggested measurement for each strategy that communities can use to assess implementation and track progress over time.

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Recommended Community Strategies and Measurements to Prevent Obesity in the United States


Appendix
Terms Used in This Report

Bike lanes: As defined by the American Association of State Highway and Transportation Officials (AASHTO), portions of a roadway that have been designated by striping, signing, and pavement markings for the preferential or exclusive use of bicyclists.

Bike routes: Cycling routes on roads shared with motorized vehicles or on specially marked sidewalks.

Coalition: A group of persons representing diverse public- or private-sector organizations or constituencies working together to achieve a shared goal through coordinated use of resources, leadership, and action.

Competitive foods and beverages: All foods and beverages served or sold in schools that are not part of federal school meal programs, including "à la carte" items sold in cafeterias and items sold in vending machines. As defined by the Institute of Medicine (IOM), competitive foods and beverages typically are lower in nutritional quality than those offered by school meal programs (1).

Complete streets: As defined by the National Complete Streets Coalition (http://www.completestreets.org), streets that are designed and operated to enable safe access along and across the street for all users, including pedestrians, bicyclists, motorists, and transit riders of all ages and abilities.

Construct validity: The accuracy of a measurement tool that is established by demonstrating its ability to identify or measure the variables or constructs that it intends to identify or measure.

Eating occasion: A single meal or snack.

Energy density. The number of calories per gram in weight.

Environmental Change: An alteration or change to physical, social, or economic environments designed to influence people's practices and behaviors.

Farm stand: Multiple and single vendors that are not part of a licensed farmers' market.

Farmer-day: Any part of a calendar day spent by a farmer (vendor) at a farmers' market (excluding craft vendors and prepared food vendors). The total number of annual farmer-days for a given farmers' market is based on the number of days that the farmers' market is open in a year multiplied by the number of farm vendors at the market on a given day.

Full-service grocery store: A medium to large food retail store that sells a variety of food products, including some perishable items and general merchandise.

Healthier foods and beverages: As defined by IOM, foods and beverages with low energy density and low content of calories, sugar, fat, and sodium (1).

Largest school district within a local jurisdiction: The school district that serves the largest number of students within a local jurisdiction.

Less healthy foods and beverages: As defined by IOM, foods and beverages with a high content of calories, sugar, fat, and sodium, and low content of nutrients, including protein, vitamins A and C, niacin, riboflavin, thiamin, calcium, and iron (1).

Local government facilities: Facilities owned, leased, or operated by a local government (including facilities that might be owned or leased by a local government but operated by contracted employees). For the purposes of this project, and according to the definition established by ICMA, local government facilities might include facilities in the following categories:

24-hour "dormitory-type" facilities: facilities that generally are in operation 24 hours per day, 7 days per week, such as firehouses (and their equipment bays), women's shelters, men's shelters, and group housing facilities for children, seniors, and physically or mentally challenged persons, not including regular public housing;
administrative/office facilities: general office buildings, court buildings, data processing facilities, sheriff's offices (including detention facilities), 911 centers, social service intake centers, day care/preschool facilities, historical buildings, and other related facilities;
detention facilities: jails, adult detention centers, juvenile detention centers, and related facilities;
health care facilities: hospitals, clinics, morgues, and related facilities;
recreation/community center facilities: senior centers, community centers, gymnasiums, public parks and fields, and other similar recreation centers, including concession stands located at these facilities; and
other facilities: water treatment plants, airports, schools, and all other facilities that do not explicitly fall into the categories listed above.
Low energy dense foods and beverages: Foods and beverages with a low calorie-per-gram ratio. Foods with a high water and fiber content are low in energy density, such as fruits, vegetables, and broth-based soups and stews.

Maternity care practices (related to breastfeeding): Practices that take place during the intrapartum hospital stay, including prenatal care, care during labor and birthing, and postpartum care. Maternity care practices supporting breastfeeding might include developing a written policy on breastfeeding, providing all staff with breastfeeding education and training, encouraging early breastfeeding initiation, supporting cue-based feeding, restricting supplements and pacifiers for breastfed infants, and providing for post-discharge follow-up.

Measure: For the purposes of this project a measure is defined as a single data element that can be collected through an objective assessment of the physical or policy environment and used to quantify an obesity prevention strategy.

Mixed-use development: Zoning that combines residential land use with one or more of the following types of land use: commercial, industrial, or other public use.

Network distance: Shortest distance between two locations by way of the public street network.

Nonmotorized transportation: Any form of transportation that does not involve the use of a motorized vehicle such as walking and biking.

Nutrition standards: Criteria that determine which foods and beverages may be offered in a particular setting (e.g., schools or local government facilities). Nutrition standards may be defined locally or adopted from national standards.

Partnership: A business-like arrangement that might involve two or more partner organizations.

Policy: Laws, regulations, rules, protocols, and procedures, designed to guide or influence behavior. Policies can be either legislative or organizational in nature.

Portion size: Amount of a single food item served in a single eating occasion (e.g., a meal or a snack). Portion size is the amount (e.g. weight, calorie content, or volume) of food offered to a person in a restaurant, the amount in the packaging of prepared foods, or the amount a person chooses to put on his or her plate. One portion of food might contain several USDA food servings.

Pricing strategies: Intentional adjustment to the unit cost of an item (e.g., offering a discount on a food item, selling a food item at a lower profit margin, or banning a surcharge on a food item).

Public recreation facility: Facility listed in the local jurisdiction's facility inventory that has at least one amenity that promotes physical activity (e.g., walking/hiking trail, bicycle trail, or open play field/play area).

Public recreation facility entrance: The point of entry to a facility that permits recreation. For the purposes of this project, geographic information system (GIS) coordinates of the entrance to a recreational facility or the street address of the facility.

Public service venue: Facilities and settings open to the public that are managed under the authority of government entities (e.g., schools, child care centers, community recreational facilities, city and county buildings, prisons, and juvenile detention centers).

Public transit stops: Points of entrance to a local jurisdiction's transportation and public street network, such as bus stops, light rail stops, and subway stations.

School siting: The locating of schools and school facilities.

Screen (viewing) time: Time spent watching television, playing video games, and engaging in noneducational computer activities.

Shared-use paths: As defined by AASHTO, bikeways used by cyclists, pedestrians, skaters, wheelchair users, joggers, and other nonmotorized users that are physically separated from motorized vehicular traffic by an open space or barrier and within either the highway right-of-way or an independent right-of-way.

Sidewalk network: An interconnected system of paved walkways designated for pedestrian use, usually located beside a street or roadway.

Street network: A system of interconnecting streets and intersections for a given area.

Sugar-sweetened beverages: Beverages that contain added caloric sweeteners, primarily sucrose derived from cane, beets, and corn (high-fructose corn syrup), including nondiet carbonated soft drinks, flavored milks, fruit drinks, teas, and sports drinks.

Supermarket: A large, corporate-owned food store with annual sales of at least 2 million dollars.

Underserved census tracts: Within metropolitan areas, a census tract that is characterized by one of the following criteria: 1) a median income at or below 120 percent of the median income of the metropolitan area and a minority population of 30 percent or greater; or 2) a median income at or below 90 percent of median income of the metropolitan area. In rural, non-metropolitan areas, the following criteria should be used instead: 1) a median income at or below 120 percent of the greater of the State non-metropolitan median income or the nationwide non-metropolitan median income and a minority population of 30 percent or greater; or 2) a median income at or below 95 percent of the greater of the State non-metropolitan median income or nationwide non-metropolitan median income (US Department of Housing and Urban Development, 24 CFR Part 81, 1995).

Violent crime: A legal offense that involves force or threat of force; according to the Federal Bureau of Investigation's Uniform Crime Reporting Program, violent crime includes four offenses: murder, forcible rape, robbery, and aggravated assault (2).

Reference
Institute of Medicine. Preventing childhood obesity: health in the balance. Washington, DC: The National Academies Press; 2005.
US Department of Justice, Federal Bureau of Investigation. Crime in the United States, 2007. Washington, DC: US Department of Justice, Federal Bureau of Investigation; 2007. Available at http://www.fbi.gov/ucr/cius2007/offenses/violent_crime/index.html.
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