MCHB EPI Atlanta Conference
December 5 - 7, 2006
How to Meet the Challenge of Childhood Obesity
MARSHALL KREUTER: Thank you Steve and Cathy. That was very informative. My name is Marshall Kreuter, and I have a question for you. How many of you in the audience in your various states, assuming that there’s someone here other than North Carolina, have a program like North Carolina? I can’t see. Okay. How many would like to have a program like North Carolina? So okay, good. How many know who Arthur Blank is? Let me just start, before I get into this discussion on the IOM Committee, with something a little bit more grounded.
Suppose you had an opportunity to submit a grant to implement one of these interesting programs either that Steve described or that Cathy described in your own area. If you’re in a state, let’s say you have a coordination--you coordinate what’s going on in a county or if you’re going to--in a community--in that community, and you went to the Arthur Blank Foundation—incidentally Arthur Blank is formerly with Home Depot’s head of the Atlanta Falcons and he has a very large foundation, actually it’s not large by way of RWJ standards but it’s a local Atlanta foundation--and they are hooked onto preventing childhood obesity, and they’d like to do something in the poorer areas of Atlanta. Let’s just say you’re there and you’re counseling and you submitted an application for a program. Do you know what one of the first questions they’re going to ask you? They’re going to ask you the question that Bill just asked Cathy, “How are you going to evaluate it?” And why do they ask the question, “How are you going to evaluate it?” Because they have a board of directors who looks very carefully at the money. And if they’re going to invest something, they want a return on their investment, don’t they? They want something to happen. So you’re then obliged to put that in there and if you can’t put it in there, you’ll have a lot of conversations with them and they’ll take it to the board and they’ll say, “This doesn’t quite cut it.” And even if you put something in there that says “evaluation,” they’re going to ask the question, “Well, what does that really mean?” And you know the story. So that’s kind of the reality.
I’d like to walk you through the report and with a mind for the practical dimensions that I was referring to just a moment ago. The report actually followed the initial report on Preventing Childhood Obesity: Health in the Balance and the goal of this second report, which is in the lower part of the screen, was basically they said, “Look. Tell us what’s going on out there, what is actually going on, and we want you to go out to three parts of the country and talk to a lot of people and then put a report together and put recommendations forth.” So an Institute of Medicine Committee really tries to make some recommendations on how to move forward. We know we have this obesity epidemic. We know the huge detrimental effects it has on chronic disease and performance, and all sorts of things. We know it’s very complicated. We know it’s an ecological issue, but tell us what the picture looks like. And incidentally, the title progress report how are we doing, it depends on who’s looking at that as to who we is. But it is a national epidemic so let’s think about it as how we’re doing as a country.
Now, I want to share with you just the names of the participants there. Steve made reference to Tom Robinson from Stanford. So there were people on the committee who are scientists, epidemiologists who are doing randomized control work on demonstrations there. You could see Eduardo Sanchez was the state--the Director of Health for the State of Texas; Shiriki Kumanyika, interested in problems of disparities; Russell Pate; another researcher Ross Brownson; Susan Forrester, a state coordinator for nutrition and health, and the likes. So it’s a broad group of people interested in grappling with the questions and the charge of the committee.
We held three symposia: one in Wichita, Kansas; one here in Atlanta; and one in Orange County, California. The one in Wichita, Kansas we did pretty much what you’ve heard so far. We had people from all over the country, not just Kansas, but kind of Midwest, mostly those people that came to inform the committee and inform themselves about, “What is going on? What are we actually doing in the area of school health? Give us some examples. Show us what’s going on.” There were programs from Arkansas and the like. They were very good and they mirrored the sentiments that we expressed to you in the first two meetings. We then went to--we came to Atlanta and the focus there shifted to community-based work and it also took a focus on policy. “What kind of policies were developed,” as was pointed out earlier today. And we heard a lot of actions being undertaken, policies at West Virginia. You know about the programs in Arkansas. There are lots of policy initiatives going on all over the country. And then at our Los Angeles meeting, we met with our colleagues in the industry. “What are you doing with respect to this issue? We’ve heard that TV--that corporate sector pushes it. Steve Gortmacher made a very correct statement earlier on.” he said, “Look, those are the guys. That’s why we—our ETHOS is set up this way. So, are we going to be able to partner, like Cathy says, if we partner excluding the corporate sector? I mean, how far do you give when you get in these meetings? Do you know that they’re trying to manipulate you and the like? They have data that they won’t give us. Their database is huge. We want that. How do you get it? You have to negotiate for it. So those are the kind of challenges that went forward. I’m not going to show this because you already know that there’s an epidemic that’s actually getting worse.
Some of the conclusions that came from the report, you can see them, we’re beginning to recognize it as a problem, as a serious health problem that has huge costs. They are actually encouraging. The report, just like you were encouraged by Cathy’s conversation, so too were we encouraged and we all should be encouraged because there’s a lot of good things going on.
The progress is slow in reducing--this problem is going to take us 15 to 20 years and we are making some progress, but very little in terms of evidence of outcomes being changed. There’s an under-investment. We need to invest more. We need better leadership. We need a better evidence-based system. The issue, again I keep referring back to Cathy’s presentation, but count the times she used the word partner or collaboration. Closing her remarks by saying, “I want to thank all of our partners. I want to thank the CDC. I want to thank Duke. I want to thank North Carolina.” So we have all these partners, and clearly it’s a collective responsibility and some people are actually doing that. But it’s a very complex and messy ecological problem for which cause-effect randomized controlled trial methodology, as we all know, probably won’t give us the answer.
Now the issue of evaluation, we need it, we need it desperately. We need a language that’s going to help us. We need techniques that are understood. And we need a system that’s going to help us get evaluation. I’d like to spend some time talking a bit about that.
In the report, we make a distinction that Larry Green has often used; between promising practices and best practices. Best practices of course being--best practices based on good science and once they’re proven, we can apply them. But here, as you heard earlier, this is a very complicated area and we just can’t wait until the best-practiced trial has been proven. We’ve got to act and so we need a little bit different assessment of what’s going on ergo evaluation. But it’s an important point that’s made in the report.
Evaluation: one of the characteristics that we drew from listening to people that when a program is done, evaluation is built-in from the outside. It’s not an afterthought, I mean when we design it we’re thinking of, “Why are we doing this?” We’re going to look over our shoulder, “We want to reduce obesity in the long run. We want to increase physical activity. We want to decrease the viewing of television. We want to increase the consumption of food XYZ,” and so forth. So the mental model of evaluation is built in to begin with and the other variables that are listed there that you can read are not at all unfamiliar to you.
Now, I want to share with you the evaluation framework because I want to go back to those people that are sitting in the room. We’re talking about 15 or so people who really want to help and they’re expressing your voice and want to try to grapple with this problem. So you’ve got us looking at it from different points of view. One person I didn’t mention up there actually represented the corporate sector. He was very, very valuable in helping us to see what’s going on. But basically, we wanted to create a framework, kind of a logic model that talked about sectors, resources inputs, what kind of strategies. A person came to the microphone and said, “Well, what about policies?” Absolutely. You can’t move forward and do this. You can’t victim blame people and say, “Change your behavior,” when you have policies that enable a corporate sector to sell them all sorts of stuff. So obviously, we need policies and we have these continuum of outcomes.
Now, the sectors have been mentioned in Cathy’s presentation very nicely: government industry, media, community school, home and faith community, etcetera. I know this is a bit small and the like and I want to show you from the standpoint of what goes on in one of these meetings. This is the product that appears in the report and it reads from left to right and basically it suggests that look, you need leadership and investment and that’s going to come from government, industry, communities, and schools. And those arrows going both ways indicate that there’s a lot of interaction back and forth. You have to have resources. You have to have input.
Then there’s a whole list of varying strategies, anyone of which, or combination of which, depending upon the circumstances you’re in are likely to be put into play. And then you see three sets of outcomes: structural, institutional, systemic outcomes. You want to have a program in Pittsburgh, incidentally not Pittsburgh, Pennsylvania but Pittsburgh, Atlanta Georgia, one mile south of here in an urban area. You want a program? Then put a playground in it. You want kids to walk around and have good food? Maybe there ought to be grocery stores where there are none. So that is to say you need to have the structural systemic issues and those are measurable endpoints that are associated with improved activity, improved consumption of food, and over time perhaps, a reduction of obesity. That question remains to be answered.
Environmental outcomes, the built environment, you know all about that, that’s an important issue. Cognitive social outcomes, behaviors, we’ve talked about behaviors. Watching TV is a behavior, physically active is a behavior, choosing the right food is a behavior, being a parent that’s mindful of what the child eats is a behavior. The doctor’s behavior to do the prescriptions is a behavior. Now all of these things then lead to outcomes that we have to have. So the goal is off to the right, the initiative is off to the left.
Now, what did the model look like before we had to produce it so that it was going to be readable? It looked like that. And let’s walk through this one. Again, on the left-hand side capacity, then you see the ecological population levels, educational policy environment. Look at the policy issues. And then under that, I’m going to wander away here and shout--is this being recorded?
UNKOWN SPEAKER: I hope not.
MARSHALL KREUTER: Okay.
UNKOWN SPEAKER: Oh, somebody’s—
UNKOWN SPEAKER: Hold on a second. He’s trying to--
UNKOWN SPEAKER: He’s turning it on or something.
MARSHALL KREUTER: Hello? Okay. What I want to point out to you here, it’s kind of a living slide because I can’t do the pointer. This is capacity, so here’s examples of capacity-building documentation system put in by the toolbox at the University of Kansas, Healthy Coalitions, micro grants provide $2,000 of support grants. I don’t know what the extent to which those are tied in but those are real, concrete, measurable examples of capacity. If you don’t have a system and you don’t have resources, you don’t have capacity. An example of the Kansas Coordinated School Program partnership of 109 schools, 227 counties, 66,000 students with the goal of increasing physical activity, that’s the stated goal related to the educational examples. There are lots of these all over the country. The new Kentucky law limits the sale of fast food in schools to one day per week; prohibits deep fried food, and requires nutrition information. This is one of hundreds of policies that are in place. Example of the built environment Morin County schools increased walking program, increases walking by 64 percent and biking by 114 percent. New supermarket in under insured Philadelphia area is in place. The Arkansas VERB Campaign, the Riverside Prime Program Campaign for fruits and vegetables consumption, and then Planet Health is listed over here as one of the measures of outcome. So we can identify activities going on right now in 2006 where there are outcomes that fit the desired goals and are moving in the right direction. We are making progress, but it is not showing up yet on the endpoint result. So we need to lead and commit to childhood obesity prevention. We need to evaluate the policies and programs, we need to monitor progress and research, and we need to disseminate promising practices.
Now, I have my own little puzzle here. This is not part of the IOM report, but it kind of reflects what my view is, I’m speaking now as a fellow public health colleague and not on behalf of the IOM Committee when I show you these next few slides. So I think the evaluation, the obesity puzzle kind of looks like this. You have the epidemiology part, that is to say the nature of the epidemic. You have to have a commitment to action, much like you heard Steve and Cathy talk about earlier. You have to have public awareness. Now, adults have to know about this issue, the public needs to know. Principals need to know, community leaders need to know, legislators need to know; and then you have to evaluate it. I think some of the pieces are in place. I do think that we do understand the epidemic. I think the public is becoming much more aware than they have in the past, and I think communities are in fact acting.
The problem is, is that our evaluation capacity is lagging behind. We can’t agree to disagree. Now, the issue is suppose every state launched complex coordinated programs linked with partners in much the same way as our colleagues in North Carolina are doing, would you measure the outcomes the same way? The likelihood is probably not. She can go to her colleagues at North Carolina or North Carolina State, but these are different people. They don’t have a place to turn to say, “These are the guidelines that we’re using.” This is our epidemic nationally, we ought to own it nationally.
So what needs to be done? So let me just paint you a picture. The opportunities for population and wide program implementation are huge in localities, as you’ve heard: schools, community, business, faith community and the like. There are regional alliances like foundations and coordinating groups and they have some impact on the possibility for implementation. Government surveillance and monitoring helps it, but it really can’t push it over the top. And academic research such as Steve was talking about, hugely important, hugely important. But in terms of its numbers, in terms of reaching the population unless it’s disseminated, is comparatively small. Now let’s invert it and ask ourselves, “Where’s the evaluation capacity?” Well, it’s very limited there. Our colleagues in churches, in communities, in schools are doing the best they can with their families and their programs just to get something in place. They need help. They need some standards. They need something that could be done that’s feasible. We don’t have that in place.
So this actually is in the report, and so if you imagine those two little triangles inversely related, the proposal is basically this: our colleagues in academic research in the government, like Steve and his colleagues, Bill and his colleagues, need to create a system, which they’re trying to do incidentally, which enable them through various state networks, which you may represent to get a both standard outcomes, measures that are comparable. I mean how many ways can you measure the built environment? Is it really—is there anything that constitutes an irreducible minimum standard? We need to find that and when we find that, we’re going to be able not only to help close that gap but we can use that evidence to show progress and link it to the outcomes. So I think the IOM report basically says we are doing good work. You are doing good work. The science is pretty darn good actually. The problem is when you get down into the boot steep in the mud in the communities, the capacity to do the evaluation while the heart is there, they’re not going to be able to do that unless we provide the system that helps them. So if in the year 2040 we want to be able to stand up, which I think we can and say, “We’ve whooping this epidemic.” It isn’t getting work and peaking out, we’re beating it. We had the smarts to be able to use the BRF flags that Bill put together and say, “Look at this epidemic. Look at those blue states, red states exploding.” If we’re smart enough to detect that in the year 2000, we’re smart enough by 2015 or 2020 to really reverse it, but we aren’t going to be able to do it unless we get that evaluation system in. Thank you very much.