Summary and recommendations for practice
- Childhood obesity is a complex issue and both individual efforts and societal changes are needed.
- Multi-setting, community-wide strategies directed at all ages and groups offer a comprehensive, equitable and intergenerational response to the problem.
- Interventions should be developed within an integrated chronic disease prevention model and with a community-based participatory research framework to maximize funding and health impact.
- Interventions that attempt to alter health behaviors must not be developed in isolation from the broader social and environmental context.
- Obesity prevention programs must include rigorous evaluation involving multiple levels and various settings to guide improvements to childhood obesity efforts in a range of contexts.
For this chapter we scanned and reviewed the published literature (e.g., PubMed and CINAHL®, The Cumulative Index to Nursing and Allied Health Literature) to select studies that were effective and examined the key elements that were consistent across the studies. With input from both authors, the evidence was synthesized and integrated into recommendations. There was no restriction on studies outside the developed countries. However, there is no large representation of studies outside developed countries, which may limit the applicability of the recommendations developed.
Social change models: what can we learn?
Population behavior is influenced by several societal subsystems, including the economy, the political system, social institutions, and culture. To influence behavior on a broad societal level, multiple subsystems must be targeted. To that end, understanding how to prevent a further rise in obesity can been informed through lessons from a range of successful attempts at social change that include increasing breastfeeding rates, seat-belt use, smoking cessation and recycling.1
Key elements identified as essential from these past successes include: recognition that there was a crisis; major economic implications associated with the crisis; a science base including research, data and evidence; sparkplugs, or leaders who can work for their cause through their knowledge, competence, talents, skills, and even charisma; coalitions to move the agenda forward and a strategic, integrated media advocacy campaign; involvement of the government at the state level to apply regulatory and fiscal authority, and at the local level to implement change; mass communication that includes consistent positive messages supported by scientific consensus and repeated in a variety of venues; policy and environmental changes that promote healthy lifestyle behaviors; and a plan that includes many components which work synergistically. Applying these social change strategies to the community environment to encourage healthy eating, increased levels of physical activity, and a decrease in sedentary behaviors is emerging as a practical way to address obesity on a large scale.2,3
Community approaches to obesity prevention
Communities have their own societal subsystems within a particular geographic area and the way in which an individual often identifies within a community is defined by race, ethnicity, socio-economic status (SES), and group memberships.4 To conduct research within communities, one must take into account the varied nature of relationships, networks, and how they may all work together synergistically.5 Community approaches can target components within the population (referred to as community-based interventions or strategies), or they can be implemented on a community-wide basis. Previous community-based approaches to change behavior and prevent disease give promise for the future of community intervention work.6–13 Furthermore, community-wide strategies directed at all ages and groups offer a comprehensive, equitable and intergenerational response to the problem, and potentially a means of treatment and prevention. The discussion that follows reviews these approaches in the context of social change and their application to obesity prevention.
Evidence in support of health improvement and disease reduction by way of community involvement began gaining ground by the 1970s. The North Karelia Project14 and the Stanford Three Community Study11,15 were among the first to break ground in this area. Each proved effective in translating educational messages to significant positive changes and cardiovascular disease risk reduction in the populations that received the interventions, as compared to control populations. The intervention strategies of these projects used mass media, low-cost lifestyle modifications and the involvement of community members. Subsequently, the National Institutes of Health (NIH) financed three major community-based intervention projects: the Stanford Five-City Project,10 the Minnesota Heart Health Program,16 and the Pawtucket Heart Health Program.7
These trials essentially provided community-wide health education over several years. The Stanford Project provided a comprehensive program using social learning theory, a communication-behavior change model, community organization principles, and social marketing methods.10 Minnesota’s multiple strategy approach provided systematic population screening for hypertension, mass media campaigns, adult and youth education programs, physician and health professional programs and community organization efforts.17 Pawtucket provided multi-level education, screening and counseling programs throughout the community.7
Community-based programs focused on youth have been carried out to increase contraception use,18 and physical activity.19 There are very few examples of community-based interventions focused on obesity, owing to the complex nature of both the etiology and the solutions, and we review several of these below.
Community-based obesity prevention interventions in children
The Pathways intervention was a randomized controlled trial conducted within the Native American communities. It was the first of its kind to take into account cultural, theoretical and operational viability in the study population and to operate on a large scale (n = 1704) in 41 schools over six years (three years of development and testing and three years of intervention). The aim of the project was to reduce body fat by promoting behavioral change and a holistic view of health among Native American school children in Grades 3–5.20 Although the intervention was largely carried out within the schools, care was taken to enlist the support of community and tribal leaders, as well as parents. The intervention was developed through a collaboration of universities and American Indian nations, schools and families with a focus on individual, behavioral and environmental factors. Pathways was successful in reducing the energy density of foods consumed by changing the school food environment.21,22 While the main outcome of the study, change in the percentage of body fat, produced no significant difference between intervention and control schools, other measurable benefits were demonstrated including a reduction in daily energy intake and percentage of energy from total fat, and increases in physical activity and for intervention verses control schools. The Pathways study demonstrated a successful marriage of theoretical underpinnings, community and family involvement, and cultural and situational appropriateness, and thereby provided an excellent community research framework upon which to build.
Shape Up Somerville (SUS): Eat Smart, Play HardTM, was one of the first community-based participatory research (CBPR) initiatives23 designed to change the environment to prevent obesity in early elementary school children.9 Academics were partnered with community members of three culturally diverse urban communities to conduct a controlled trial to evaluate whether an environmental change intervention could prevent a rise in BMI z-scores in young children through enhanced access and availability of physical activity options and healthy food throughout their entire day. The SUS intervention focused on creating multi-level environmental change to support behavioral action and maintenance and to prevent weight gain among early elementary school children through community participation. Specific changes within the before-, during-, and after-school environments provided a variety of increased opportunities for physical activity. The availability of lower-energy-dense foods, with an emphasis on fruits, vegetables, whole grains and low-fat dairy was increased; foods high in fat and sugar were discouraged. Additional changes within the home and the community, promoted by the intervention team, provided reinforcing opportunities to be more physically active and improve access to healthier food. Many groups and individuals within the community (including children, parents, teachers, school food service providers, city departments, policy-makers, health care providers, before- and after-school programs, restaurants and the media) were engaged in the intervention (see http://nutrition.tufts.edu/research/shapeup for details).
These changes were aimed at bringing the overall energy equation into balance, specifically, this intervention was designed to result in an increased energy expenditure of up to 125 kcals per day beyond the increases in energy expenditure and energy intake that accompany growth. A central aim of the intervention was to create a community model that could be replicated nationwide as a cost-effective, community-based action plan to prevent obesity at local levels. After the first school year of intervention (8 months) in the intervention community, BMI z-score decreased by −0.1005 (P = 0.001, 95% confidence interval −0.1151 to −0.0859) compared to children in the control communities after controlling for baseline covariates.9 This approach addressed the complex environmental influences on energy balance and ensured maximal reach within a population of children.
Community-based interventions are also being effectively implemented in other parts of the world. Recently, an Australian intervention program utilizing the socio-ecological model (Be Active, Eat Well)24 was evaluated and found to be successful in a number of areas. Intervention children had significantly lower increases in body weight, waist, waist/height, and BMI z-score than comparison children. Further, the intervention was shown not to increase health inequalities related to obesity and was also deemed to be safe as changes in underweight and attempted weight loss were not different between the two groups of children.24
More interventions that focus on multi-faceted community-based environmental change approaches using key elements of other successful social change models (a recognized crisis, economic impact, evidence based, government involvement) are needed.1 Advanced community-based research approaches to turn the tide on childhood obesity will require training of future leaders in community research methodology, increased funding to conduct rigorous trials, and acceptance of the study model as viable from the broad scientific community.
The benefits of this approach to obesity prevention
There is broad agreement that, to reduce obesity, priority needs to be given to multi-strategy, multi-setting prevention efforts, particularly in children.25,26 Controlled obesity prevention trials in childhood are few in number, mostly short term (one year or less), focused on only a single or a few strategies (education or social marketing only) and settings (school-based only) and largely showed little or no impact.27–29 Until recently, the studies that did show an impact tended to be high-intensity, less sustainable approaches (e.g., extensive classroom time promoting individual behavior change).27–29 It is clear that innovative approaches that work at multiple levels and are flexible, effective, cost-effective, equitable and sustainable are urgently needed and, as discussed above, multi-setting community-based interventions hold promise as one such option.2,25,26,29,30
The success of a multi-setting intervention approach may be the result of a number of factors. An approach such as this works within a framework which recognizes that multiple factors affect a community’s function and, in turn, the health of the individuals within it. The socio-ecological model identifies five levels of influence on an individual’s health: intrapersonal, interpersonal, organizational, community and environment/policy. This framework also recognizes that these factors (environment, working conditions, economy, education, culture and health systems), affect an individual’s health in both direct and indirect ways. Reviews of the intervention literature, particularly in obesity prevention have shown that interventions that use these frameworks to guide their design are more likely to be successful.29 This also appears to hold true across a number of public health issues, as discussed above.
Behavioral interventions have had limited success at altering individual health outcomes. However, even when shown to have some efficacy, the sustainability of the modest changes in health behavior is low and does not translate to population-level health improvements. Limitations of this type of intervention are that they largely ignore the social context that shapes behaviors and that the complexity of the physiological changes brought about by behavior change is often not recognized. Interventions of this type treat individual behaviors as separate from social context and biology.31
Community-based, and community-wide, interventions can also address risk factors that are common to a number of chronic diseases. The integrated chronic disease prevention (CDP) model has developed from a recognition of the preventable risk factors shared by leading chronic diseases.32 Key concepts in the integrated CDP model include an ecological perspective, intersectoral action, multi-level intervention, and collaborative processes. The multiplicity and complexity of this approach is captured in a definition put forward by Shiell:
[Integrated chronic disease prevention is an approach] … that targets more than one risk factor or disease outcome, more than one level of influence, more than one disciplinary perspective, more than one type of research method, or more than one societal sector, and which targets populations—rather than individuals—as a unit.32
The influence of the ecological perspective is evident in that integrated CDP frameworks consider the interdependence between individuals and the broader socio-environmental context. For example, a community-wide intervention to improve the delivery of preventative services to children in the United States achieved far-reaching changes.33 The intervention approach was based on systems theory, which suggests that many opportunities for improvement exist in the interactions between elements of a system. For this intervention, the application of this theory resulted in viewing care delivery as a series of processes extending from the home to the primary care practice and other community health and social services. The intervention activities were directed at the community, practice and family level. At the community level, positive effects were seen in state and community policies, which led to sustainable changes in organization practices and funding approaches. At the practice level, alignment and integration of services delivered by multiple practices resulted in reduced duplication, improved coordination and changes in service delivery. At the family level, the intervention resulted in improved child and maternal health outcomes.33
An additional benefit of a multi-setting community-wide approach is its potential to improve the health and development of all children in the community. Interventions that attempt to address at least some of the social determinants of health have the potential to address population-level determinants of ill-health, rather than individual characteristics. They can be equity focused and reduce the socio-economic gradient that currently exists for almost all health outcomes.
This approach can also positively influence individual behaviors through addressing the societal and environmental influences at the community level. Interventions that target multiple aspects of individual environments have the ability to make the more health promoting options easier, and over time can also shift behavioral and cultural norms in a sustainable manner. Targeting environments also represents an upstream approach, as children in low-income families live in environments that limit social and economic opportunities, access to healthy foods and opportunities for physical activity.34 In the Shape Up Somerville intervention program, a signifi-cant reduction in z-BMI was seen after one year in the intervention children.9 This intervention engaged the community widely and was specifically focused on changing children’s environments at school and also enhancing access and availability of healthy eating and physical activity options throughout the entire day for children, including before- and after-school programs.9 Also, as a result of the intervention, there were changes in the home and community, which provided reinforced opportunities for increased physical activity and improved access to more nutritious food.9
Best practice recommendations for intervention activities
In their comprehensive synthesis of the evidence of reducing obesity and related chronic disease risk in children and youth, Flynn et al (2006) present recommendations for a broad range of sectors, organizations and health professionals, which are based on the available evidence and gaps in knowledge identified during the synthesis. With regard to intervention activities, the recommendations29 can be summarized as follows:
- Population-based interventions should be developed to balance, support and extend the current emphasis on individual-based programs.
- Obesity prevention programs need to be developed with rigorous evaluation components in community and home settings where limited program activity is evident and effectiveness is unknown.
- Interventions need long-term implementation and follow-up to determine the sustainability of program impacts as on body weight.
- To maximize funding and health impact, interventions should be developed within an integrated chronic disease prevention model and with a CBPR framework.
- Program design process should be developed to allow continual incorporation of new elements associated with greater program effectiveness, using an action research model.
Taking this further, Glass and McAtee have developed a multi-level three-dimensional framework to examine health behaviors and disease in social and biological context. They challenge us to develop better theory and data to understand how social factors regulate behaviors, or distribute individuals into risk groups, and how these social factors come to be embodied.31 This is needed because while we are knowledgeable about the behaviors that lead to ill health and disease, relatively little is known about how these behaviors arise, become maintained and can be changed. By advancing the study of the social determinants, Glass and McAtee suggest that more effective population interventions can be developed. Accordingly, continuing to conduct interventions that attempt to alter health behaviors in isolation from the broader social and environmental context will continue to provide disappointing results. The authors emphasize the need to focus on the health behaviors and the mediating structures that lie between the behavioral sphere and the macro-social context. These mediating structures are termed “risk regulators”, and in the obesity context are, for example, cultural norms, area deprivation, food availability, laws and policies, and workplace conditions.31 These risk regulators influence the two key behaviors related to obesity, nutrition and physical activity, in a way that is dynamic and extends over the life course. Accordingly, population interventions to prevent obesity cannot attempt to influence health behaviors without attempting to address at least some of these risk regulators and a more contextual understanding of health behaviors and health service usage, for example, would increase the effectiveness of obesity prevention interventions and public health policies.31
There is growing recognition of the need for a common risk factor approach to public health interventions. This approach is the basis of the integrated chronic disease prevention model, which arose from the need to increase the efficiency and efficacy of traditional, single-disease focused prevention efforts.32 The best interventions will build on existing collaboration and networking among local health authorities. However, structural factors (e.g., political, financial) must be in place for interventions to be implemented and thoroughly evaluated.32 Policies and program funding that target all of the determinants of health must be collaboratively developed by government departments such as health, education, and human resources and employment.32 Findings from the Alberta Heart Health Project show that for an integrated approach to chronic disease prevention to succeed government support is vital and the voluntary, professional, academic, and private sectors must contribute to action on the root causes of health. Effective leadership is important and the public health system, which can be viewed as the embodiment of publicly-funded organized efforts to prevent disease and promote health, must take responsibility for facilitating the inter-sectoral collaborations fundamental to integrated chronic disease prevention.32
Current evidence on obesity prevention and other public health successes demonstrates that early intervention and prevention is more effective and less costly then treatment efforts. Given the complexity of childhood obesity, both individual efforts and societal changes are needed. These changes will require the involvement of multiple sectors and stakeholders, particularly collaboration between community, government and academia. In addition, evaluation needs to occur at multiple levels and settings to guide improvements to childhood obesity efforts and develop initiatives that can be used in a range of contexts.
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