Lessons from Obesity Prevention in Public Health UNC-Chapel Hill, August 2008

1. Lessons from Obesity Prevention in Public Health UNC-Chapel Hill, August 2008

4. Best Practices in Obesity Prevention • Putting “Best Practice” into perspective • Finding “evidence-based” programs • A model for achieving the greatest impact for programs • Reframing media advocacy

6. Environmental & Policy approaches ENORMOUS potential Yet, the amount of well done policy research/evaluation in “real world” settings is small compared with the reach and potential.

7. Environmental & Policy approaches What constitutes acceptable evidence?

8. Remember: lack of or insufficient evidence doesn’t mean it should not be done…just that we don’t yet know if it is effective.

9. Sage advice • We need evidence from both research and practice • There are MANY research and practice efforts currently underway in NC and nationally • We can’t afford to wait until all the evidence is in, but we can make informed choices of where to spend time and resources • “Based on the best available evidence, as opposed to waiting for the best possible evidence”Preventing Childhood Obesity, Institute of Medicine

12. NC Programs – NAP SACC

13. NC Programs – NAP SACC • Research findings to date • 96 child care centers across 33 NC Counties. 3 evaluation groups: intervention, minimal intervention and control • Shows promise as a environmental intervention • Web training may be used in conjunction with or in place of in-person training • Self-assessment instrument can be used as an outcome measure • Results in modest behavior change among children

14. Kids Eating Smart Moving More (KESMM) • Pediatric obesity intervention study funded by NICHD (built on 4 years of pilot work) • 24 primary care practices serving Medicaid families throughout the state of North Carolina will participate • Focuses on improving primary care providers and case managers abilities to: • identify and assess children at risk for or already overweight • communicate effectively with families/link them to community resources • influence local policies related to improved nutrition and opportunities for physical activity. Intervention materials include: • Provider and case manager toolkits and training • Color-coded BMI charts • Starting the Conversation Nutrition and Physical Activity evidence-based tools • Self-Monitoring logs • Families Eating Smart and Moving More toolkit materials • Primary care community partnership advocacy workshops • Dates of funding: September 1, 2005- June 30, 2010

25. Public Health Impact

26. Translating evidence into practice The RE-AIM Model • Purpose • To assess the potential for a given intervention to have a public health impact

27. Which is Better?

28. It Depends • Who delivers? • Program A: Trained master’s level health educators • What resources? • Program A: Group exercise area and counseling rooms • How easy is it to implement? • Program A: Moderately difficult

29. It Depends • Who delivers? • Program B: Administrative assistants in community health center • What resources? • Program B: Email access and participants can do activities at home or in neighborhood • How easy is it to implement? • Program B: Moderately easy

30. How Scalable is it? Program A: 20 people per class session, (90-minute counseling session and 3 one-hour classes each week) Program B: 100 people per session (includes monitoring of physical activity and sending out weekly newsletters) What does it Cost? Program A: 33 hours per week for 6 months from health educator for every 16 successes (20 people per group) Program B: 8 hours per week for 6 months from administrative assistant for every 20 successes. It still depends

31. How can we use RE-AIM in practice? • Developing a new intervention • Adapting an existing intervention • Choosing between alternative interventions • Assessing an intervention as part of quality improvement • Framing questions for evaluation purposes

32. Why RE-AIM • Reach large numbers of people, especially those who can most benefit • Be widely adopted by different settings • Be consistently implemented by staff members with moderate levels of training and expertise • Produce replicable and long-lasting effects and be maintained at reasonable cost

33. RE-AIM Perspectives on Generating Relevant Evidence

34. If we want more evidence-based practice, we need more practice-based evidence. L. W. Green, 2004

35. Media Advocacy It is now clear that standards of population health are overwhelmingly affected not so much by medical care as by the social and economic circumstances in which people live and work. Richard Wilkinson (2000)

36. Land of Controversy: the Upstream Territory • Distant from perceived immediate causes • Perceived as minimizing individual responsibility • Addresses issues of social or public policy • Often confronts well-financed corporate interests • Few short term indicators of success

37. The definition of downstream! It’s almost as though the system encourages people to get sick and then people get paid to treat them. Dr. Matthew E. Fink, Former president of Beth Israel In “The treatment of diabetes, success often does not pay” New York Times, January 11, 2006

38. Basic Public Health Question Will the public’s health improve primarily as a result of individuals getting more and better knowledge about personal factors Or Groups getting more skills and opportunities to participate in changing public policies?

40. Media Advocacy & Reframing the Issue

41. Frames are mental structures that help people understand the world, based on particular cues from outside themselves that activate assumptions and values they hold within themselves. Berkley Media Studies Group

42. Frames • People interpret words, images, actions or text by fitting them into an existing conceptual systems that gives them order and meaning. Just a few cures, words, images, trigger whole conceptual frames. • Often expressed in metaphors • Horse races in political campaigns, • War metaphors in health threats • Sports and business metaphors

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45. Framing & Media Advocacy • Framing battles in public health Illustrate the tension between individual freedom and collective responsibilities. • The two frames of market justice and social justice influence public dialogue on the health consequences of corporate practices.

46. Frame support for public health as social justice • A shift to social justice “frame” demands a rebalancing these values with others that Americans also hold. • How an issue is described or framed can determine the extent to which it has popular or political support. • We must articulate the social justice values motivating the changes we seek in specific policy battles that will be debated in the context of news coverage.

47. Self-determination and self discipline Rugged individualism and self-interest Benefits based solely on personal effort Limited government intervention Voluntary and moral nature of behavior Shared responsibility Interconnection and cooperation Basic benefits should be assured Strong obligation to the collective good Government involvement is necessary Community well-being supersedes individual well-being Market Justice vs. Social Justice Values

48. Pew Center poll of 44 countries found that US residents • We are more likely to believe that twe are in control of our lives than to see our lives as subject to external forces. • Dominant factors: self determination, personal discipline and hard work • Reinforcing individualism.

50. How is Obesity Being Framed • Center around appearance and health • Include the idea that the direct cause of obesity is overeating and that overeating is bad for health and bad for appearance. But frames evoke more • Expressed in terms of character, people become obese when they lack will power • More deeply imbedded…those who lack willpower are of poor character These underlying assumptions about obesity can be evoked whenever obesity is referred to.