Best bets what to do? - Home | Deakin€¦ · WHO Collaborating Centre for Obesity Prevention Logic model for OPIC interventions 1 Intervention dose is either 1 or 0 (intervention,

WHO Collaborating Centre for Obesity Prevention

Steven Allender

Best bets – what to do?

Professor of Population Health

Co-Director

WHO Collaborating Centre for Obesity

Prevention

Deakin University

Australia

Senior Researcher

Coronary Heart Disease Statistics

Department of Public Health

University of Oxford

Port Fairy Yacht Club September 3rd & 4th 2012


What works for children?


There is lots of evidence

WHO Collaborating Centre for Obesity Prevention 2011


Review summary

Aims

This review primarily aims to... determine the effectiveness of evaluated interventions intended to

prevent obesity in children, assessed by change in BodyMass Index (BMI).

Secondary aims were to examine the characteristics of the programs and strategies to answer the

questions “What works for whom, why and for what cost?”

Search methods

The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March

2010 and searched relevant websites. Non-English language papers were included and experts

were contacted.

Selection criteria

The review includes data from childhood obesity prevention studies that used a controlled study

design (with or without randomisation). Studies were included if they evaluated interventions,

policies or programs in place for twelve weeks or more.


Review results

55 studies (36 more than 2009)

Majority children aged 6- 12 years

Some evidence that programmes were effective at reducing adiposity.

Strong evidence of child obesity prevention programmes reducing on BMI

Promising policies and strategies:

· school curriculum that includes healthy eating, physical activity and body image

· increased sessions for physical activity and the development of fundamental

movement skills throughout the school week

· improvements in nutritional quality of the food supply in schools


Review results

Promising policies and strategies:

· environments and cultural practices that support children eating

healthier foods and being active throughout each day

· support for teachers and other staff to implement health promotion

strategies and activities (e.g. professional development,

capacity building activities)

· parent support and home activities that encourage children to be more

active, eat more nutritious foods and spend less time in

screen based activities


Prioritisation


Prioritisation!!!

WHO Collaborating Centre for Obesity Prevention Geelong

Overview – Sentinel Site for Obesity

Prevention

• Three demonstration projects in

community-based obesity prevention

• Aim: To build the programs, skills and

evidence necessary to prevent obesity

among children and adolescents

• WHO Collaborating Centre for obesity

prevention, Deakin University

• Barwon South-west region


SSOP Projects - Objectives

Three standard objectives in all three projects:

1. To increase the capacity of relevant Geelong

organisations to promote healthy eating and

physical activity

2. To increase the awareness of the project’s key

messages in homes and early childhood settings

3. To evaluate the process, impact and outcomes

of the project


Sentinel Site for Obesity Prevention

• Features and innovation: – Focusing resources into a defined

geographical area

– Community capacity building

– Multi-strategy, multi-setting intervention

programs

– Monitoring

– Evaluation


Barwon-South Western region

Geelong

Regional

population

~300,000

Geelong

population

~200,000


Logic model for OPIC interventions

1 Intervention dose is either 1 or 0 (intervention, control) or $$ (economic input – all schools)2 Capacity is leadership, skills/knowledge, structures, resources3 Relevant environments are schools, homes, neighbourhoods, churches4 Weight, BMI, BMI-z, waist, waist:height, %fat, prevalence of o/w+obesity

Intervention

Dose1

Δ Community

capacity2

Δ Environments3

Δ Knowledge,

attitudes, beliefs,

perceptions etc

Δ Behaviours Δ Anthropometry4

INPUTS

POPULATION

MEDIATORS

INDIVIDUAL

MEDIATORSOUTCOMES

MODERATORS

Ethnicity, socio-cultural

factors, gender, age, SES

Δ QoL

Δ QALYs gained

Δ Policy

= Measured = Modelled

Logic model


<5 y/o


Romp & Chomp specific objectives –

developed through ANGELO process

• Increase:

– Consumption of

water and milk

– Consumption of fruit

and vegetables

– Active play at home

– Structured active

play in early

childhood settings

• Decrease:

– Consumption of high

sugar drinks

– Consumption of

energy dense snacks

– TV viewing time


Romp & Chomp - outcomes


4-12 y/o


BAEW specific objectives

• Increase

– The proportion of

primary school

children who

walk/cycle to school

– The amount of active

play in the after-

school time and on

weekends

– Consumption of fruit

• Decrease

– Time spent watching

TV & playing on

computers or

electronic games

– Consumption of high

sugar drinks

– Consumption of

packaged, energy

dense snacks


BAEW – Physical activity

interventions Physical activity strategies • After-school activities program

• Be Active Arts program

• Walking school buses and walk to school days

• Promotional materials (for example, balloons, stickers)

• Sporting club coach training and equipment

• Sets of pedometers

Screen time • TV power-down week, including a 2-week curriculum

• Interactive, glossy, children’s newsletters (5 x 1600, distributed through schools)

• Teacher fliers (linking to children’s newsletters)


Less weight and waist gain in intervention group

over 3y

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0BMI (kg/m2) z-BMI Weight (kg) Waist (cm)

Un

its

of

Ch

ange

(In

t ve

rsu

s C

om

p)

p = 0.056

p = 0.017

p = 0.014

p = 0.000

Adjusted for confounders: age, gender, height, duration of follow up Sanigorski et al Int J Obesity 2008


Preventing unhealthy weight gain

adolescents

It’s Your Move! An adolescent obesity prevention project conducted in the Barwon-South Western Region of Victoria


It’s Your Move!

• Community-based, 3-year obesity prevention program in 5 secondary schools in Geelong

• 1 of 4 sites in the Pacific OPIC

Project (Obesity Prevention

In Communities)

• Funded by DHS, NHMRC,

VicHealth, DoHA

Geelong


Evaluation

• Outcome and impact evaluation

– Before and after measurements

• Intervention area (E Geelong/Bellarine) versus

comparison area (rest of Barwon-SW region)

– 3,075 high school students participating in evaluation

– Outcome measures

• Body composition, body mass index, waist

circumference

– Impact measures

• Behaviours, knowledge, attitudes, quality of life

• Process evaluation


Evaluation

• School Environmental Surveys

– 3 part survey

• Part 1 completed by principal [25 questions]

• Part 2 completed by canteen manager [12 questions Part 2 ]

• Part 3 completed by 3 teachers [individually, 27 questions]

• Socio-cultural studies

– Qualitative and quantitative studies

– S-C influences on food, PA, body size perception

• Quality of Life

– 2 Quality of Life questionnaires validated for adolescents


Measurements and surveys


It’s Your Move! Intervention

Three standard objectives

- Building Capacity

- Social Marketing

- Evaluation

Four nutrition objectives

- Water versus sweet drinks

- Breakfast

- Fruit and vegetables

- Food @ School

Two physical activity objectives

- Walking and cycling

- Getting active

One innovative objective

- Healthy body weight, shape and size


Water versus Sweet Drinks

• Water bottle – teacher and booklist

• Vending machine changes

• DVD presentation developed by Ambassadors

• Curriculum: Sweet drink display

• Water fountains

• Water Policy

• School Newsletters

• Postcard for classrooms

• Water Bottle Rules

• Social Marketing • ‘H2O, way to go!’


Lessons learnt

• To present two intervention strategies which

worked well:

– Student Ambassador Model

– Food @ School framework

And one which did not work well:

– School lunchtime activities

• To understand the critical success factors for

intervention strategies


Student Ambassador Model

• Selection of students

– Dependent on the school: School Project

Officer selection, interview, or application

• Formal training: Certificate II Sport and Event

Management

– Included: planning retreats to provide skills,

knowledge, leadership, and positive peer

feedback


Role of Student Ambassadors

• For the project

– Planning (action plan and annual plans)

– Leadership and spokespeople

• For the schools

– Peer-led interventions, advocacy for change,

leadership

• For themselves

– Leadership training and practice


Student Ambassadors


Student Ambassadors: Key Learnings

• Vital component to ensure that the

school interventions were peer-led

while building the students’ own

capacity

• Highly valued and accepted role by

the students (considered positive &

cool)

• Program required high

Project Co-ordinator input


Food @ School Framework

• A whole school approach to food

– Including several action plan strategies:

• Curriculum materials

• Supportive school environments

• Healthy eating messages

• Policies and support materials for breakfast,

camps, excursions and sport days, catering,

fundraising, canteens, vending machines, water,

and occupational health and safety and rewarding

students in the classroom


Food @ School: Implementation

• ‘Bottom-up’ approach

– Project coordinators working with staff and

students through to the school governance

systems

– Evolved from practice to policy

• Combined the multiple food and healthy

eating strategies together

• Long process (up to 3 years) to ratify


Food @ School Framework: Key Learnings

• A staged, ‘bottom up’ approach allows time for gaining buy-in and flexibility but makes it a long process

• Elements were tailored to each school’s context so that the final policy differed significantly across the five schools

• Value in combining nutrition objectives

• Significant input by the project team


Lunchtime Activities

• Lunchtime activities at schools such as:

– Physical Activity: yoga, walking groups, dance, 3 on 3

basketball, soccer tournaments

– Food: soup, sushi, salad wraps, juice

• Tended to start with great enthusiasm but were

relatively short lived


Lunchtime Activities: Key Learnings

• Lunchtime activities and one off events (e.g. physical activity or healthy eating promotional days)

– Initially positive & good for raising awareness

– More readily implemented than policy or environmental changes

– Required high School Project Officer input

• High project staff input

– Took their time and attention away from the more sustainable activities


Conclusions: Intervention

• School-based interventions need to focus on structures and policies more than activities

• Work through the existing school structures,

– this may take several years in the case of comprehensive food policies.

• Student Ambassador program does require coordination resources but has multiple student and program benefits


What is the intervention in CBIs?

• Community capacity building approach

– Leadership and commitment

– Funding and resources

– Organisational relationships and structures

– Knowledge and skills

• Multiple settings and participatory process

– The approach and process need to be robust

– Content is determined and specified by the

community players Bell et al Health Prom Int 2008


Community Readiness to Change

Level of readiness to change

(y axis)

9. High level of community

ownership

8. Confirmation/ expansion

7. Stabilization

6. Initiation

5. Preparation

4. Pre-planning

3. Vague awareness

2. Denial/Resistance

1. No awareness

0

1

2

3

4

5

6

7

8

9

Intervention schools Comparison schools


IYM: Individual school changes

Percentage point change in overweight/obesity prevalence

Millar et al Obesity Rev 2011 12(suppl 2): 20-28

-8.1

8.9

4.3

1.8

0.0

3.8

-1.4

0.0 -0.3

-4.7 -5.6

-8.0

-20.0

-15.0

-10.0

-5.0

0.0

5.0

10.0

15.0

20.0

% c

han

ge

ove

rwe

igh

t/ o

bes

e b

as

eli

ne t

o f

ollo

w-u

p

Unit change (shaded) in Community Readiness to Change from baseline to follow-up

No change +1 increase +2 increase +3 increase

Millar et al., forthcoming


7 Community Demonstration Projects:

Capacity Building Pyramid

PROJECTS

Fun ‘n’ Healthy in Moreland (FHM)

Colac Be Active Eat Well (BAEW)

Geelong Romp & Champ (R&C)

E Geelong It’s Your Move! (IYM)

Fiji Healthy Youth

Healthy Community (HYHC)

Tonga Ma’alahi Youth (MY)

Mangere Living for Life (LFL)

PI – 4

Co-Inv – 16

Staff, RFs, HDR – 64 FHM 13; BAEW, R&C, IYM 24;

HYHC 11; MY 8; LFL 8

Partner organisations ~ 102 (eg schools, LGAs, health orgs, community orgs,

peak bodies, govt agencies, commercial entities)

FHM 28; BAEW, R&C, IYM 40, HYHC 17; MY 14; LFL 17

Other Stakeholders ~ 283 (eg funders, other settings, linked organisations)

FHM 55; BAEW, R&C, IYM 85, HYHC 78; MY 35; LFL 30

Children & adolescents* ~ 31,500 FHM 3,000; BAEW, R&C, IYM 17,000, HYHC 6,000; MY 1500; LFL 4000

* Children in intervention

communities. Families

and others influenced by

the interventions are

additional to this. This

number again are in the

comparison communities.

Response rates 35-70%

Research

Practice

Policy


What could be done directly? (1)

• Policies (ie school rules)

– Access to school grounds, equipment etc

– Need to make sure that policies are not unduly

preventing informal PA

– Can only apply where schools have jurisdiction

– Policies are important because they set the

boundaries and reflect the culture

• Curriculum

– More ‘Active’ curriculum – moving (or even

standing) embedded into learning

– Content area of learning about PA & fitness



• Social marketing

– Developing messages and materials

– What are the motivators (fun, social, alert and awake, cool) and

aware of ‘costs’

– Usually done as ‘campaign’ (sustainability?)

• Programs

– Supporting informal PA (esp for those less active, non competitive)

– Often need leaders because not formalised

• Events or other initiatives

– Can be good (awareness, something new, launch etc)

– One-offs take a lot of effort and can distract from influencing

systems and embedding change


What could done with the systems? (1)

• Leadership support and role modelling

– Who are the champions for any policy changes needed to

have school rules (and culture) promoting informal PA?

– Policy often requires ‘bottom-up’ pressure and top level

stewardship through the system

– Staff and student leaders as role models

• Information systems

– What’s happening? How do you let people know?

• Financing

– Equipment

– Supervision



• Partnerships/networks

– Links with community opportunities (more often

formal and organised sport or activities)

– Promotion within the school (reciprocal visits,

information flows, meeting people etc)

• Workforce development

– Does the existing workforce training for teachers

and staff need to be strengthened in this area?

– Volunteer training systems


Food at school

• Includes: food sold in canteens; vending

machines; food at events; food for fundraising;

food as rewards; role modelling etc

• While food at school does not include a large

amount of a student’s annual energy intake, it

has an enormous ‘Lighthouse Effect’

• Tough but most important area with many

stakeholders

• Needs to in all school’s action plans


School Environment – Canteen Menu

NONE of the primary schools measured in Victoria met the Healthy

Canteen Guidelines


Specific food issues

• Sugar-sweetened beverages including fruit juices

– A priority to reduce, closely linked with weight gain

and poor oral health

• Foods high in fat, salt and sugar

– Often cheap, tasty, easy to prepare, long shelf life,

higher profit margins, promoted, in demand etc

• Fruit

– Quite high consumption at school, easy to promote

• Vegetables

– V few meet guidelines, harder to promote at school



• Policies (ie school rules)

– Comprehensive school food policy – developed,

promoted, implemented, monitored

– Takes a lot of effort and needs high level champions

– Reflection of school values versus realities (student

well being vs profit, healthy ideal vs current habits)

• Curriculum

– Substantial scope within curriculum (health and

other area)

– Linking what is taught with what is practised



• Social marketing

– Developing messages & materials (especially linked to new policy)

– What are the motivators and what are the ‘costs’

– Who is the audience (students, teachers, parents, school board)

• Programs

– Growing, cooking, eating, cuisines etc etc

– Embedded in ongoing school activities

• Events or other initiatives

– Many options (but events are a lot of work)

– Good for launching new initiatives

– Structural options eg gardens



• Leadership support and role modelling

– Leadership is absolutely critical for getting healthy school

food policies through the system – many stakeholders

– Staff and student leaders as role models

• Information systems

– Communication systems are vital – keeping everyone in

the loop, up-coming, positive feedback etc

– Monitoring and feedback on progress of school canteen

• Financing

– Profits from canteen, food fundraisers etc

– Altered profit margins, more preparation of fresh food



• Partnerships/networks

– Many food-related potential partners in the

community (farm to plate)

– Links with schools who have made the transition

to healthy food schools

• Workforce development

– Does the existing workforce training for canteen

managers and teachers need to be strengthened

in this area?

– Volunteer training systems


33% of students were trying to lose

weight

Other IYM findings of note


Project plans

• Name?

• Overall aim – reducing unhealthy weight gain

and improving well being in adolescents

• Objectives (SMART - what will be achieved?)

– Comprehensive food at school policy

– Active transport (Melrose), informal PA

(Deakin), mental health (Calwell)

• Strategies (how will the objective be achieved)

• Actions (who will do what by when)


Project plans

• Living documents (version control)

• Focus of the management meetings

• Augmented by GANTT charts

• Used for the evaluation of

– Process

– Embedding in systems

– Modifying systems


‘In’ the system – Food at school

• To develop, ratify, implement and monitor a

comprehensive school food policy

• Strategies

– Governance and leadership eg school food steering

committee with mandate and timelines

– Information systems on progress with feedback eg canteen

sales, student satisfaction

– Resources to get to full implementation (project $$), ongoing

business model

– Partnerships (eg NA), networks (eg other schools), contracts

(eg with providers)

– Workforce development eg canteen manager training

– Social marketing targeting decision-makers


‘In’ the system – Active transport

• To increase the proportion of students (living within 30

minutes walking radius of school) using AT regularly to/from

school by x%

• Strategies

– Supportive environments eg bike sheds, cycle

lanes, crossing safety, safe routes

– Social marketing

– Training programs for cycling

– Partnerships with council

– Information systems on transport to school


‘On’ the system – leadership

• Leadership and governance (for improving

environments and behaviours related to healthy eating and PA)

– To optimise the school’s existing leadership

and governance systems, and include new

structures and processes for identifying and

supporting diverse champions

• Seeding question for actions

– What needs to happen (or is happening) to

achieve the above optimised and enhanced

leadership and governance systems?


On the system – information

• Information and communications (for improving

environments and behaviours related to healthy eating and PA)

– To optimise the school’s existing information

and communications systems and include new

intelligence loops such that information is

gathered and effectively communicated to the

right audiences


– What needs to happen to achieve the above

optimised and enhanced information systems?


‘On’ the system – resources

• Finances and resources (for improving environments

and behaviours related to healthy eating and PA)

– To mobilise from existing and new sources,

sufficient resources to sustain effective actions



optimised and enhanced finances/resource

systems?


‘On’ the system – partnerships

• Partnerships, networks and organisational

relationships (for improving environments and behaviours

related to healthy eating and PA)

– To optimise existing relationships and create

new relationships to enhance actions



optimised and enhanced partnership and

relationships?


‘On’ the system – workforce

• Workforce development (for improving environments

and behaviours related to healthy eating and PA)

– To enhance existing WF development

systems and identify new opportunities for

staff, students and volunteers to increase their

skills and confidence to promote healthy

eating and PA



optimised and enhanced workforce

development systems?


Steven Allender

Best bets – what to do?

Professor of Population Health

Co-Director

WHO Collaborating Centre for Obesity

Prevention

Deakin University

Australia

Senior Researcher

Coronary Heart Disease Statistics

Department of Public Health

University of Oxford

Port Fairy Yacht Club September 3rd & 4th 2012


Actions Description Leadership Information Financing Partnerships Workforce

Policy That at least 50%

of food at school

is ‘green’

Principal and school

leadership to develop and

drive policy

Parent committee,

teacher/s, school

leadership team

Student representative

committee

Canteen sales data

Student surveys of

choice

Audit of whether

policy is followed

Release

mandate to

make profit for 3

months to

assess viability

Find ways to

reduce cost of

healthy food

Nutrition Australia

ACT Health

ACT Education

Canteen provider

IYM Geelong

IYM School Co-

ordinator

Training of

canteen manager

and staff

Role modeling of

school teachers

Curriculum Kids learn how to

traffic light label

foods and apply

this to canteen

School curriculum

committee

Lead teachers in nutrition

subjects

Canteen management

Provided in class to

students

Canteen menu

Teacher time to

develop

curriculum

National curriculum

authority

Nutrition Australia

Key teachers in

each subject

Canteen

management

Social

marketing

Newsletters and

posters

supporting the

‘green food’

school

IYM Co-ordinator

Student Rep Council

Change in attitudes

to green food

% green foods

posted on school

web site

Support for

printing posters

Web site

support

Other IYM schools

Other ACT schools

Student/s or staff

to produce

article/flyer/s

School web

admin

Programs Food at school

program teaching

healthy cooking

and reading of

food labels

Teacher/s to coordinate

programs

Number provided

and attendance

Equipment

Teacher/

facilitator time

Church food

provision

Local s/markets

Students,

volunteers, clubs,

teachers,

associations

Events Healthy school

challenge

Nude food days

IYM Co-ordinator

Student Rep Committee

Parent and community

committee

Amount of

packaging used

Nutrition Australia

etc.

High % red food intake

Kids choose red foods

Used as rewards in

class Sold at special events

Sold in canteen

Green foods available

at school

Red foods available

from surrounding shops

Red foods available

from home

Red foods are available

Principal wants better

NAPLAN results

High demand for red

foods

Canteen provider is a

business

Need to be profitable

Cross subsidize other

activities

School management

Red foods common at

home

Staff role model red

foods

Red foods are normal

Red foods are cheap

Red foods are cool

Principal wants good

student behavior

Aim to meet national

curriculum Obesity prevention a

key focus

School food >50%

green

Canteen manager

Canteen cross

subsidizes other

activities

Canteen sales data

IYM COORDINATOR


Investment in nutrition and PA activities


What causes obesity?

Positive energy balance

• More energy is taken in than is spent, causing

an excess of energy which is converted into fat


What causes obesity?

Positive energy balance

• More energy is taken in than is spent, causing

an excess of energy which is converted into fat

Energy

in Energy

out


PHYSICAL ACTIVITY FOOD CONSUMPTION

Energy in

Energy out


The Process

-The main question to remember is ‘why’

-The process can continue until the analysis reaches

a point where solutions become apparent, or when a

certain number of levels, commonly three, have

been detailed.

Pacific Research Centre for the Prevention of Obesity and Non-communicable Diseases

Starting problem

Cost Availability Preference


The Process



LOW INTAKE FRUIT


Why is cost high


The Process – Activity



LOW INTAKE FRUIT


High import

duties

Low levels local

production


Red foods: Foods and drinks categorised as Red are energy dense but have little nutritional value. Most are high in saturated fat, salt and/or sugar.

Green foods: excellent sources of important nutrients and

represent the five food groups needed for optimum

health and wellbeing. They are low in saturated fat, added sugar and salt.

WHO Collaborating Centre for Obesity Prevention High % red food intake








Red foods available at

school

Red foods available


Red foods available

from home





school

Red foods available


Red foods available

from home




Used as rewards in


Sold in canteen


school

Red foods available


Red foods available

from home




Used as rewards in


Sold in canteen


school

Red foods available


Red foods available

from home


High demand for red

foods


activities



Used as rewards in


Sold in canteen


school

Red foods available


Red foods available

from home


High demand for red

foods


activities


Red foods are cheap

Red foods are cool



Used as rewards in


Sold in canteen


school

Red foods available


Red foods available

from home


Canteen cross

subsidizes other

activities

High demand for red

foods


business



activities

Goals of school

management

Red foods common at

home


foods


Red foods are cheap

Red foods are cool



Used as rewards in


Sold in canteen


school

Red foods available


Red foods available

from home


Principal wants better

NAPLAN results

Canteen cross

subsidizes other

activities

High demand for red

foods


business



activities

Goals of school

management

Red foods common at

home


foods


Red foods are cheap

Red foods are cool

Principal wants good

student behavior

Aim to meet national

curriculum

Documents

Best bets what to do? - Home | Deakin€¦ · WHO Collaborating Centre for Obesity Prevention Logic model for OPIC interventions 1 Intervention dose is either 1 or 0 (intervention,