Obesity Prevention & Control in Underserved Populations: - - PowerPoint PPT Presentation

Obesity Prevention & Control in Underserved Populations: asset-based sociocultural environmental change

Antronette K. Yancey, MD, MPH, FACPM Associate Professor, Health Services Dept. Co-Director, Center to Eliminate Health Disparities UCLA School of Public Health

Introduction

Ain’ Like There’s Hunger

Sweet tooth Salt tooth Chocolate tooth Jonesin’ for fries Mickey D’s And Popeye’s But no runnin’ tooth Swimmin’ tooth Stretchin’ tooth Dancin’ tooth Weight liftin’ tooth After all Ain’ like there’s hunger…

Summary Points

Current strategies are not containing the

• besity 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 critical—society has key role in sharing, with individuals, the high “costs” of healthy lifestyle change/maint.

• Obj. 19-2

Total White Female Male Black Female Male Mexican American Female Male Target

Adult Obesity: 1988-94 to 1999-2000

0 10 20 30 40 50 Percent

1988-94

Note: Data are for ages 20 years and over, age adjusted to the 2000 standard population. Obesity is defined as BMI >= 30.0. Black and white exclude persons of Hispanic origin. Persons

• f Mexican-American origin may be any race.

Source: National Health and Nutrition Examination Survey, NCHS, CDC.

Race/Ethnicity

Staying healthy is easier for some than for others…

UPPER SES LOWER SES

Education College GED or HS Housing Own / Safe Rent / Safe? Physical activity Gyms / Parks, “move Parks?, “move insecure” secure” Neighborhood stores Fruit/ Veg, food secure Drugs/ Alcohol, food insecure Police Helpful Abusive Healthcare Private Doc ER, VA Sick leave Accrued None Leisure priority Exercise Rest Work conditions Safe, hi decis. lat., Hazardous, lo decis. lat., no + flex time no flex time Child care Nanny/ hi-qual facil. Family/ neighbor, lo-qual facil. Elder/ disabled care HHW/ hi-qual facil. Family/ neighbor, lo-qual facil. Criminal just. sys. Little contact Much contact Premature M&M Low High

Years of Potential Life Lost by Ethnicity (per 100,000)

2000 4000 6000 8000 10000 12000 14000 Total Afr Am Am I nd AsianPI Latino W hite

Lesser Effectiveness of Key Environmental I nterventions in Underserved Groups: Example

Posting of Signs Promoting Stair Usage

(suburban Baltimore mall)

Overall, stair use increased from 4.8% to 6.9%,

7.2%, depending upon which of 2 signs used

Among whites, increased from 5.1% to 7.5%,

7.8%

Among blacks, changed from 4.1% to 3.4%, 5.0% Among n’l wt, inc from 5.4% to 7.2%, 6.9% Among overwt, inc from 3.8% to 6.3%, 7.8%

Andersen, Franckowiak, Snyder et al., Ann Int Med, 1998;129:363-369.

Excess physical environmental risk in underserved communities:

Pervasive targeted commercial marketing Distance to private fitness facilities Few worksite fitness opportunities Few/poor neighborhood recreation

facilities

Lesser neighborhood safety Poorer public/less reliable private

transportation

Adapted from Kumanyika S. Obesity in Minority Populations. In Fairburn G & Brownell K, Eating Disorders and Obesity. A Comprehensive Handbook, 2002.

Which billboard(s) is (are) about physical activity?

Excess economic environmental risk in underserved communities:

Limited investment in public parks/recreation facilities Fitness facility fees Cost of exercise & sports equipment & fees Less stable employment patterns Fewer trained PE instructors Large PE classes Poorly equipped facilities Poorly maintained sidewalks Fewer traffic calming devices, e.g., speed bumps Ample car “accommodation,” e.g., parking, high-

speed/multi-lane roads

= “Move insecurity”1, 2

1Jahns & Jones, AJPM 2004;26:186 2Yancey, AJPM 2003;25(3Si)

Buford Highway in Atlanta: housing populated by low-income recent immigrants to the US

Common Uncommon

Excess sociocultural environmental risk in underserved communities:

Cultural attitudes about work, activity, rest Fears about safety Prevalent obesity/norms Female roles Cultural reverence for cars Hairstyle-related concerns about sweating Increased screen time, e.g., TV viewing,

movie-going

LA’s ESPN Radio 710 AM Ad

“We’re the prime rib on a dial full of tofu”

• -March 2006

Cultural reverence for SUVs?

Physical Activity Levels, % L.A. County Adults, 1999

District Sedentary (< 10 min/wk)

County 41 + 1

Compton 45 + 6 South 50 + 9 Inglewood 46 + 6 Long Beach 37 + 5 West 31 + 3

Physical I nactivity Levels: TV

viewing/computer use, % L.A. County Adults, 1999

District TV/ Computer Use > 3 hrs/ d (95% CI)

County 21.7 20.6-22.9

African Am. 36.5% 32.4-40.5

• Am. Ind./Nat. Am.

34.2% 16.1-52.3 Asian/Pacific Isl. 21.1% 17.6-24.6 Latino 15.8% 14.3-17.3 White 24.3% 22.4-26.2

Physical Activity Levels:

TV viewing> 2 hrs/d vs. regular PA, % California adolescents, 2001

Group TV Viewing Regular PA > 2 hrs/ d CDC/ ACSM def.

African-American males

67.5% 79.9%

African-American females

62.4% 67.7%

White males

47.9% 81.4%

White females

39.2% 71.2%

Prevalence of Obesity among LAC Adults by Ethnicity, 1997-2002

5 10 15 20 25 30 35 Afr-Am API Latino W hite 1997 1999 2002

SPA 8 SPA 5 SPA 2 SPA 3 SPA 4 SPA 7 SPA 6 SPA 1

Unfit Children by Assembly District and Service Planning Area Los Angeles County 2001

5 5 10 Miles

N

Prepared by Los Angeles County DHS, Public Health, Office of Health Assessment and Epidemiology, December 2002 Data source: California Center for Public Health Advocacy, 2001 California Physical Fitness Test Note: California Assembly Districts became effective in the November 2002 election, based on the 2000 Census. New SPA boundaries (September 2002)

Percentage of Unfit Children 19.1 - 34.1 34.2 - 37.8 37.9 - 40.9 41.0 - 45.1 45.2 - 54.0

SPA 1 SPA 2 SPA 5 SPA 3 SPA 4 SPA 7 SPA 6 SPA 8 5 5 10 Miles

N

Prepared by Los Angeles County DHS, Public Health, Office of Health Assessment and Epidemiology, December 2002 Data source: California Center for Public Health Advocacy, 2001 California Physical Fitness Test Note: California Assembly Districts became effective in the November 2002 election, based on the 2000 Census. New SPA boundaries (September 2002)

Overweight Children by Assembly District and Service Planning Area Los Angeles County 2001

Percentage of Overweight Children 16.9 - 22.4 22.5 - 24.6 24.7 - 26.5 26.6 - 30.3 30.4 - 36.8

Self-Perceived Overweight by Ethnicity & Gender,

% LA County Adults Female Male AA Overwt 67 29 AA Nml wt 20

• API Overwt

86 46 API Nml wt 28 10 Lat Overwt 80 41 Lat Nml wt 26 9 W Overwt 84 46 W Nml wt 21 4

Influence of Self-Perceived Weight Status on PA,

% LA County Adults

Overall, 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

• Overwt. self-perception not assoc. with sedentariness

among white women, the only one of the 6 ethnic- gender groups included in which BMI< 25 normative

In multivariate analysis, self-perceived overweight,

not BMI, predicts sedentary behavior (OR= 1.40, CI 1.19, 1.64)

Yancey, Simon et al., Obes Res, In press, 2006. Yancey, Wold et al., Am J Prev Med, 2004;27:146-52.

SB19 Early Implementation Study: Baseline demographics

Ethnicity of middle school students (7

th graders)

Number

Percent

American Indian 2 0.1% Asian 203 12.7% Filipino 90 5.6% Hispanic/Latino 1,116 70.1% African American 89 5.6% Non-Hispanic white 85 5.3% Multiple responses, Other 8 0.5% Free or reduced lunch eligibility Not eligible –pays full fare 490 30.7% Eligible for reduced price lunch 204 12.8% Eligible for free lunch 830 51.9% Other 74 4.6%

Distribution of dieting classification, by BMI-for-age

Sex-specific BMI for age classification Lose weight Gain weight Work to stay the same Not try to control weight Total Underweight 0% 76.67% 13.33% 10% 100% 23 4 3 30 Desirable weight 28.94% 14.52% 29.25% 27.28% 100% 279 140 282 263 964 At risk of overwt. 73.21% 2.81% 14.80% 9.18% 100% 287 11 58 36 392 Overweight 87.70% 1.57% 6.94% 3.80% 100% 392 7 31 17 447 Total 958 181 375 319 1833

Proportion of 7th graders reporting depressiveness in last year, by dieting status

y = -0.0557x + 0.4641 R

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

lose weight gain weight stay the same not try to control weight

N = 1,767 7th graders OR =0.79, 95% CI: .72, .86, p < .0001, controlling for age, gender and subsidized lunch eligibility

Health behavior correlates of not trying to control weight:

Those not trying to control weight vs

• ther diet status categories ate fast food

less often (p = .04), ate sports bars less often ( p = .004), drank sports drinks less often (p = .001), drank sweetened juices less often (p = .02) and participated in more minutes of physical activity in PE class (p = .03). They also did better academically than other students (p = .005).

*note: logistic regression models included age, gender and meal subsidy eligibility as covariates.

Current Population Status

Little change in leisure time physical activity

(PA) during past several decades, but marked increases in sedentary entertainment, transportation, and other ADLs (Sturm, 2004)

PA levels within increasingly sedentary,

deconditioned, overweight population are unlikely to increase primarily through individual motivation and volition (relatively little demand for goods & services or political will to push for aggressive legislative policy change)

Population benefit estimates

• f risk factor change: PA

3-minute bouts of physical activity 10 times per

day lowers triglycerides to same extent as 1 continuous 30-minute bout of PA (Miyashita et al., 2006)

Type 2 DM risk was 50% lower among individuals

physically active at any level, and 66% lower among those at least moderately active (James et al., 1998)

Sedentary behaviors (e.g., TV watching) as well

as sub-optimal > moderate PA levels contributed to DM & obesity risk over 6 yrs in women (Hu et al., 2003)

Population Obesity Control:

Early stage in development

To avoid exacerbating health risk/disease burden disparities, push strategies (skip- stop/slowed hydraulic elevators, restricted proximal parking, non-discretionary time exercise breaks, walking meetings) should be prioritized over pull strategies (building trails & parks, offering gym membership subsidies/discounts) at this early stage of development of environmental and policy approaches—make it easier to do it than not to do it!

Shift in health promotion field (Spectrum of Prevention)

The most effective and sustainable PH intervention approaches of the past two decades are the more “upstream” ones (structural/ environmental vs. individual-level), involving social norm change:

Tobacco control Alcohol consumption and driving

Population Obesity Control:

Early stage in development (cont.)

Synergy will occur when supply (physical

environmental access & appeal) meets demand (individual/ sociocultural motivation, prioritization, valuation, skills/interests, political will)

Demand must be created—need to structure in

“unavoidable” PA experiences which increase aerobic conditioning, build skills & self-efficacy, foster enjoyment, elevate mood & energy, increase taste for water-bearing foods & less highly-sweetened beverages

Spectrum of Prevention (1st level)

Level of Prevention Definition of Level Examples of Obesity Prev. Efforts

Strengthening individual knowledge and skills

Enhancing an individual’s capability of preventing illness/injury & promoting health Exercise classes Cooking classes Home visits/ instruction Exercise prescriptions (Rx)

African-American Women Fight Cancer with Fitness

Community-based, randomized, controlled, 2-

group prevention trial conducted, 1996-2000

Nearly 900 women screened to produce final

sample of 364

8-wk, 2-hr/wk nutrition-PA discussion & exercise

instruction vs. cancer screening lecture-discussion seminars in black-owned community gym

$50 incentive per assessment (except baseline);

1-yr gym membership (all), up to 1½ -yr (C)

1o outcome measures: BMI, WHR, %body fat by

BIA; 2o: 1-mi run/walk; med: diet/PA, CESD

Comparing FCF and FCK conditions on weight change from baseline to 2-months follow-up

Grps varying in lbs change from baseline to 2 mos follow-up

more than 20 lb weig 11-20 lb weight gain 6-10 lb weight gain 1-5 lb weight gain little weight change 1-5 lb weight loss 6-10 lb weight loss 11-20 lb weight loss > 20 lb weight loss

Percent

30 20 10

experimental conditi

control group experimental group

Comparing FCF and FCK conditions on weight change from baseline to 12-months follow-up

Grps varying in lbs change from baseline to 12 months

> 2 l b w e i g h t g a i n 1 1

• 2

l b w e i g h t g a i n 6

• 1

l b w e i g h t g a i n ' 1

• 5

l b w e i g h t g a i n l i t t l e w e i g h t c h a n g e 1

• 5

l b w e i g h t l

• s

s 6

• 1

l b w e i g h t l

• s

s 1 1

• 2

l b w e i g h t l

• s

s > 2 l b w e i g h t l

• s

s

Percent

30 20 10

experimental conditi

control group experimental group

Treadmill time over 12 months

Estimated Marginal means for time to do 1 mile TOT_TIME 4 3 2 1 E s t i m a t e d M a r g i n a l M e a n s 20.5 20.0 19.5 19.0 18.5 18.0 17.5 17.0 Expmtl conditions FCF control group FCF expmtl group

Fighting Cancer with Fitness:

Summary of Findings

Sustained effects at 12 mos: Body composition (measured)

Non-obese controls BMI increased signif less than obese

controls (+ .46 kg/m2vs. + 1.32 kg/m2, p= .045)

Central adiposity stabilized in controls (+ .57, p= .7 vs.

+ 2.67, p= .0001) Nutrition (self-report)

Total kcal & % kcal from fat (decreased) Fruit/vegetable intake (increased—experimental gp only)

Fitness (measured)

1-mi run/walk times improved in both groups compared

with baseline

Yancey, McCarthy, Siegel et al., J Women’s Health, 2006, in press

Spectrum of Prevention (4th level)

Level of Prevention Definition of Level Examples of Obesity Prev. Efforts

Fostering coalitions and networks

Bringing together groups and individuals for broader goals and greater impact

Local project coalitions & advis. comm. Healthy Cities coalitions Governor’s Councils

• n Physical Fit. &

Sports

Media Project: national print advertising content analysis

Funded by CA DHS Nutrition Network Comparing magazines matched by content area and age-gender of audience targeting African Americans, Latinos in English, Latinos in Spanish, and “general audiences” (whites) Digital cameras used to record photos of all ads in each of 4 issues from 2004 (1 per season) Electronic abstraction form captures domains including: content, size, nature of appeal, ethnic-specific language (dialect, colloquialisms), ethnicity of subjects, weight status of subjects

Mainstream / white African- American Latino (English) Latino (Spanish)

Sports

Sports Illustrated Black Sports

Sports Illus. Latino

Social/ Lifestyle

People Jet Hispanic People

Women’s

Cosmopolitan

Essence Latina

Cosmopolitan

Current affairs

Reader’s Digest Ebony Selecciones

Men’s

Maxim King Oye Maxim

Music

Rolling Stone Vibe Urban Latino Batanga

Media Project: 5-city outdoor advertising content analysis

Funded by CA DHS, Univ TX, Univ Penn & RWJF Cities: LA, Philadelphia, Austin, Sacramento, Fresno Comparing high & low SES predominantly black, Latino, & white neighborhoods (all 6 categories not available in all cities, e.g., no high SES black areas in Sacramento and Fresno) Utilizing secondary data from CHIS, LACHS, grocery store scanner purchase data for correlational analyses

Media Project: 5-city outdoor advertising content analysis

Digital cameras and GPS units used to record a photo and location coordinates

• f all ads in zip code

Electronic abstraction form captures domains including: content, size, nature

• f appeal, density, visibility, ethnicity of

subjects, weight status of subjects

Preliminary findings

Absence of billboards and near-absence of other outdoor

advertising in affluent white neighborhoods—existing ads unrelated to weight

Essentially no outdoor advertising of PA-promoting goods &

services in any community, but large amount sedentary entertainment & transportation ads in low-inc. communities

Pervasiveness of advertising in low-income white & Latino

communities, but more fast food, sugar-sweetened and alcoholic beverages in latter

City of LA has moratorium on new billboards, but in low-inc.

Latino comm., large # new side of bldg. ads similarly framed

Findings must be interpreted in light of historical covenants, fewer ads traditionally in unincorporated areas

Spectrum of Prevention (5th level)

Level of Prevention Definition of Level Examples of Obesity Prev. Efforts

Changing

• rganizational

practice & policy Adopting regulations and shaping norms to improve health

Protocols for MD assessment, sliding fees, counseling & referral Worksite policies (movement breaks, vending, refreshments) School PE content & delivery

Translating Evidence-Based CDC/ACSM Recommendations into Culturally-Targeted Intervention

Integrating 10-’ PA bouts into organizational routine:

Minimal intensity environmental intervention, e.g.,

stair prompts

Short bouts accommodate higher proportion

sedentary individuals (incremental change)

Variable (max moderate) intensity, low-impact PA

accommodates higher proportion overweight/obese and disabled individuals (higher perceived exertion, discomfort, functional limitations)

Passive (vs. active) strategy relies less on individual

motivation & facility access (fewer early adopters)

Translating Evidence-Based CDC/ACSM Recommendation into Culturally-Targeted Intervention

Integrating 10-’ PA into organizational routine:

Movement to music integral to African-American,

Latino culture—dancing normative for adults

Short bouts minimize perspiration, hairstyle

disturbance

Social support & conformity desires drive

participation (collectivist vs. indiv. orientation)

Addresses less activity conducive outdoor

environments (safety, utility, aesthetics)

Designed for organizational settings for work,

worship, other purposes--less disposable t, $

Disseminating Evidence-Based I ntervention:

• Incorp. brief exercise bouts into organizational routine

7 examples in different settings:

5 “efficacy”

local health dept—Fuel Up/Lift Off! LA state health dept—FitWIC federal agency—Pausa para tu salud school—Take 10! private corp.—Westinghouse, L.L. Bean

2 adoption/implementation

CBOs—Community Health Council’s REACH 2010 proj. FBOs—Health-e-AME Physical-e-Fit proj.

Fuel Up/Lift Off! LA

Video/audiotape excerpt: movement break (Lift Off) demonstration www.ph.ucla.edu/cehd

LAC Fitness & Wellness Study: Design

Randomized, controlled, post-test only,

intervention trial testing the effects of incorporation of a 10-min exercise break into staff meetings & training seminars lasting > 1 hr

Outcome measures: (1) participation by

sedentary/overweight individuals; (2) mood/affect; (3) satisfaction with health status/fitness level

LAC Fitness & Wellness Study: Results

Full study implemented in 26 meetings with

449 individuals, 11 intervention & 15 control

Sample: 73.6% female; x= 41 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%

LAC Fitness & Wellness Study: Results (cont.)

More than 90% of meeting attendees participated

in the exercises Among relatively sedentary participants:

Intervention participants’ satisfaction with fitness

levels more highly correlated with PA stage of change (r= 0.59) than controls (r= 0.38, z= -2.32, p= 0.02) Among sedentary participants:

Intervention participants’ self-perceived health

status ratings were significantly lower than controls (OR= 0.17; 95% CI= 0.05, 0.60; p= .0003

Yancey, McCarthy, Taylor et al. 2004;38:848-856

WIC Staff Wellness Training WIC Staff Wellness Training

California Fit WIC Staff Wellness Training

Significant findings:

Increased perceived workplace support for

staff PA (96 vs 58%, p= 0.002) and healthy food choices (85 vs 28%, p= 0.001)

Change in types of foods served during

meetings (72 vs 24%, p= 0.002) & PA priority in workplace (96 vs 71%, p< 0.02)

Increased self-reported counseling behaviors

with WIC parents promoting physical activity (64 vs 35%, p< .05) & sensitivity in handling weight-related issues (92 vs 58%, p< 0.01)

Crawford, Gosliner, Strode et al., AJPH, 2004;94:1480-1485

Pr

• puesta de c olabor

ac ión

Implementac ión de la pausa par a la Salud:

E

va lua r lo s fa c to re s de rie sg o c a rdio va sc ula r pre vio a la inte rve nc ió n de a c tivida d físic a .

Pro mo ve r de 15 a 20 minuto s de a c tivida d físic a de ntro

de la jo rna da la b o ra l, inic ia ndo c o n 10 minuto s ha sta a lc a nza r má ximo 20 minuto s.

Pro mo ve r la o rie nta c ió n a lime nta ria de ntro de la

jo rna da la b o ra l.

L

• g ro s a lc a nza do s e n un a ño 0.9 mmHg me no s de

pre sió n a rte ria l, 0.4 kg / m2 me no s de BMI y 1.6 c m me no s de c intura pro me dio e n lo s tra b a ja do re s e n un a ño .

L a ra A, Ya nc e y A, T a pia -Co nye r R, Mc Ca rthy W e t a l., in pre pa ra tio n, 2006

Community Health Council’s REACH 2010 project--African Americans Building a

Legacy of Health: Process evaluation

I ntervention: 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 PA & healthy food choices into their regular conduct of business; (3) provision of a personal training experience to key organizational leaders; (4) development of a small grants program for ID/creation/promotion of PA opportunities.

Sloane, Diamant, Lewis et al., J Gen Int Med 2003;18:1-8

CHC’s African Americans Building

a Legacy of Health:

Process evaluation

Measures: Primary dependent measure–level

• f organizational support for physical activity

integration, as reflected in intensity of interventions selected for participation;

Results: Nearly half (> 100) of the 220

participating organizations demonstrated active support for physical activity integration, with > 25% committed at the highest level of support.

Yancey, Lewis, Sloane et al., J Pub Health Mgmt Prac, 2004;10(2):118-123

Health e-AME Physically-e-Fit Project:

Process evaluation

3-year CDC-funded faith-based PA promotion

program delivered by training church reps

Recruited >200 of the 500 black (AME

denomination) congregations throughout SC

CBPR model 21 (54%) of churches reported having

implemented at least one of menu of active and passive PA promotion options, including 15 using “Exercise Your Faith for Ten!” CD (adaptation of LA Lift Off!) in gospel choir rehearsals, Sunday school, bible study

Wilcox, Laken, Anderson et al., Health Promotion Practice, in press

PAAC/ TAKE10!

Group RCT—collaboration between University of Kansas & ISLI 40+ schools (>70% free/reduced lunch eligibility rates) in three Kansas cities—Kansas City, Lawrence, Topeka Incorporate 10-minute PA breaks into regular academic lessons, e.g., math, science, English curricula Accumulate 90-100 minutes per week of PA in addition to PE & recess (constrained in low-resource/-performance schools) No additional teacher preparation time Changes environment Participation “mandatory” Training through existing in-service mechanism—little added cost Easily perpetuated and replicated FUN!

Intervention

Average PAAC Minutes/Week At the End of Year 1

10 20 30 40 50 60 70 December February April

Minutes per week

These values are averages across all intervention schools

50 55 60 65 70 75 80 Sept Oct Nov Dec Jan Feb March April May

Minutes per week Months

These values are averages across all intervention schools

Average PAAC Min/Week

Average PAAC Min/Wk At the End of Year 2

Community “Cost-Sharing:” Policy Change Opportunities

1. Leveraging your managerial and fiscal roles to mandate or incentivize healthy/fit workplace practices for your subsidiaries, suppliers, community-based

• rganizations (CBOs) to which you

donate $, health plans with which you contract, etc.

• 2. Changing your internal organizational

culture (social norms) to create healthy/fit organizational practices, in your social life and in your workplaces.

Community “Cost-Sharing”

“Healthy/ fit” organizational PA & nutr. promotion practices include core & elective components, e.g., 10’ movement (or walking) breaks in meetings/ functions & at certain time(s) of day; walking meetings; stair prompts; leading employee groups to stairs in moving between work activities; restricted near parking; incentivized distant parking; model & reward fidgeting and lifestyle PA integration (e.g., less high heel & tie wearing, pedometer wearing, formal recognition/kudos); > 50% healthier & competitively priced vending options; healthier refreshments at meetings/events, e.g., F+ V, water

Community “Cost-Sharing”

3. Encourage local school officials to:

• a. Train teachers of PE in SPARK-type models

emphasizing coop. vs. compet., engaging all kids

• b. Move student drop-off location as far away from

door as possible, e.g., behind playing field, to maximize distance youth must walk to attend class

• c. Incorporate Take 10!, Lift Off! or other exercise

breaks into academic curriculum 2x/day, eg, math

• d. Incorporate structured exercise breaks into PTA

meetings, school board meetings, community dialogues, staff meetings & other gatherings to raise visibilty/priority of PA promotion in addressing childhood obesity

Community “Cost-Sharing”

4. Advocate for legislative policy changes at the local levels to facilitate structural integration of PA, e.g.,:

• a. traffic diversion or calming devices decreasing

vehicle accommodation and increasing pedestrian accommodation or “level of service,” e.g., adding/repairing sidewalks, adding traffic signals, bike lanes, center city malls excluding autos, sidewalk “bulb-outs”

• b. requirement for equal placement (# s) of

physical gaming machines (e.g., Dance, Dance, Revolution) as substitute for some sedentary games in video arcades

Dance, Dance, Revolution

• Players are challenged to

match their dance steps with the flashing arrows on the screen while keeping up with the high-energy beat of the music

• 5 pairs of dance pads
• Increase coordination,

endurance

• Very popular in video

arcades, typically with long lines of youth awaiting turn to use machines

Community “Cost-Sharing”

• 4. Local legislative policy advocacy… (cont.)
• c. redressing inequitable distribution of free-for-use

recreational facilities favoring high-income areas and poor upkeep of parks & playgrounds in low- income areas

• -explore litigation (Public Health Law Center)
• -explore limited liability protection (“Good

Samaritan” laws) for organizations making facilities available for joint use before-/after-hours

• -explore incentives for locating supermarkets &
• ther produce vendors in low-income areas

Community “Cost-Sharing”

• 5. Leveraging your organizational

purchasing power to create demand for healthier food choices (whole wheat vs. white rolls, fruit

• vs. pastries) and support vendors

supplying healthy (low-fat dairy, F+ V, whole wheat vs. pasta, skinless poultry/fish, soy products), tasty, culturally compatible meals.

“We must become the change we wish to see in the world.”

• -Mahatma Gandhi

Community “Cost-Sharing”