# Presentation: 574869

## Planet Health: The Prevention of Childhood and Adolescent Obesity Through School-Based Intervention 

**Steven Gortmaker, Ph.D.**
- Harvard School of Public Health /Harvard Prevention Research Center
- Talk at MCH Epi Conference December 2006

## Overview

**Strategies to prevent obesity in Planet Health 2nd Edition (in press)**
**Reduce sugar sweetened beverages, fast food, unhealthy fat, TV**
**Increase fruits and vegetables, physical activity**
**Planet Health interdisciplinary curriculum**
**Effectiveness and cost-effectiveness**
**Dissemination: Teachers and students like it!**
**Translation to Life course Impact: Thinking Outside the School**

## Causes of the Overweight Epidemic: The Science of Energy Balance

## Obesity Fundamentals

**Obesity is caused by Energy Intake in excess of  Energy Expenditure**
**The daily energy imbalance driving the epidemic is on average small -  an extra sugar sweetened beverage per day – but greater for obese youth. **
**Social context is important (e.g. sodas everywhere) **

- Koplan JP,Dietz WH. Caloric imbalance and public health policy. JAMA. 1999;282:1579-81. Wang YC, Gortmaker SL,
- Sobol AM, Kuntz KM. Estimating the energy gap among U.S. children: A counterfactual approach. Pediatrics, Dec 2006.

## The Important Forces: 

**	****F**ood producers and the "Fast Food" 			industry - if they’re successful, we all eat 	 	more
**	****A**dvertisers for food and video/film 			industries - if they’re successful, we all buy 		more
**	****T**elevision and video/film production and 		distribution industry - if they’re successful we 	all watch more

## Sugar-sweetened beverages contribute to childhood obesity incidence

## An extra can of sugar sweetened beverage per day (150 kcal) can lead to an excess of 5 pounds per year body weight

## Trends in Beverage Consumption Among US Adolescents, USDA 1965-96 Cavadini et al. Arch Dis Child 2000

**Consumption (ml/d)**

**Boys**

**Girls**

**Trends in Beverage Consumption Among US **_**Adolescents, USDA 1965-96**_ ***Cavadini et al. Arch Dis Child 2000***

## Soft Drink Consumption and Overweight

**“****For each additional serving of sugar-sweetened beverage consumed, both BMI  (0.243 kg/m2; P=0.03), and incidence of obesity (odds ratio 1.60; P=0.02) increased.” **

**Ludwig DS, Peterson KE, Gortmaker SL. Lancet 2001, 357:505-8**

- Soft Drink Consumption and Overweight

## Reducing Intake of Sugar Sweetened Beverages Can Reduce Overweight Among Youth

- A school-based randomized controlled intervention found that intake of carbonated drinks could be decreased, and that this change was accompanied by a decrease in percentage of overweight and obese children (-7.7%; 95% confidence interval 2.2% to 13.1%)

**James J, et al. BMJ 27 April 2004.**

**Reducing Intake of Sugar Sweetened Beverages Can Reduce Overweight Among Youth**

## Sugar Sweetened Beverage Consumption and Weight Gain and Diabetes Incidence in Adult Women

**“...****women consuming 1 or more sugar-sweetened soft drinks per day had a relative risk of type 2 diabetes of 1.80; P<0.001 for trend) compared with those who consumed less than 1 of these beverages per month.” **

**Schulze et al. JAMA 2004, 292:927-34.**

**Sugar Sweetened Beverage Consumption and Weight Gain and Diabetes Incidence in Adult Women**

## The growth of the fast food industry and increasing portion sizes make it easy for children to overeat

## Slide 14

## “A large fast food meal 

- Ebbeling CB, Pawlak DB, Ludwig DS.
- Childhood obesity: public health
- crisis, common sense cure. Lancet
- 2002;360:473-82.

- “A large fast food meal
- (double cheeseburger,
- french fries, soft drink,
- desert) could contain
- 2200 kcal, which...
- would require a full
- marathon to burn off”

## First picture from the surface of Mars

## Health, 2005 Sep;95(9):1575-81 . 

- Austin SB, Melly SJ, Sanchez BN,
- Patel A, Buka S, Gortmaker SL.
- Clustering of fast food restaurants
- around schools: a novel
- application of spatial statistics
- to the study of food environments.
- American Journal of Public
- Health, 2005 Sep;95(9):1575-81 .

## Slide 18

## Fast Food and Diet of Children and Youth

**Fast Food and Diet of ****Children and Youth**

**On days that children and youth eat fast food – they consume an extra 126 kcals/day (P<0.0001)**
**Higher income children, non-Hispanic African Americans, and children in the South eat more fast food**

## The Important Forces: 

**	****F**ood producers and the "Fast Food" 			industry - if they’re successful, we all eat 	 	more
**	****A**dvertisers for food and video/film 			industries - if they’re successful, we all buy 		more
**	****T**elevision and video/film production and 		distribution industry - if they’re successful we 	all watch more

## Television Viewing and Energy Balance: The Science

**How can television viewing cause obesity?**
**Evidence in support of hypothesis**

## Hypothesized Impact of Television Viewing on Obesity

- Obesity

- Television
- Viewing

- Dietary
- Intake

- Inactivity

- Dietz WH, Gortmaker SL.  Do we fatten our children at the tv set?  Obesity and television viewing in children  and adolescents. Pediatrics, 1985; 75:807-812.
- Gortmaker SL, Must A, Sobol AM, Peterson K, Colditz GA, Dietz WH. Television viewing as a cause of  increasing obesity among children in the United States, 1986-1990. Archives of Pediatrics and Adolescent  Medicine, 1996;150:356-362.

## “...children currently view as many as 40,000 commercials on television and cable per year.” “Finding: Children are exposed to extensive advertising for high-calorie and low-nutrient foods and beverages and very limited advertising of healthful foods and beverages during their daily television viewing.”

**J. Michael McGinnis, Jennifer Appleton Gootman, Vivica I. Kraak, Editors*****. *****Food Marketing to Children and Youth: **
**Threat or Opportunity? Institute of Medicine of the National Academies*****. *****The National Academies Press. **
**Washington, D.C. 2006.**

## Television Viewing and Total Energy Intake A Longitudinal Observational Study 

**Television Viewing and Total Energy Intake**** ****A Longitudinal Observational Study**** **

**For each hour increase in television viewing, total energy intake increases 167 calories per day (P<0.0001) **

- Wiecha JL, Peterson KE, Ludwig DS, Kim J, Sobol A. When children eat
- what they watch: impact of television viewing on dietary intake in youth.
- Archives of Pediatrics and Adolescent Medicine, 2006 Apr;160(4):436-42 .

## Slide 26

## Randomized Controlled Trials: Television and Obesity 

**School-based intervention**: **primary grades****;** impact on mean BMI (Robinson. JAMA.1999. )
**Clinical Intervention:** Obese children and youth; impact of reducing inactivity on overweight (Epstein et al. Health Psychol. 1995.)
**School-based intervention**; **Planet Health** **;** reduced television predicts reduced obesity among middle school girls (Gortmaker et al. Arch Pediatr Adolesc Med. 1999)

## Planet Health

**An Interdisciplinary curriculum for 6****th****-8****th**** grade students**

- Carter J, Wiecha J, Peterson KE, Gortmaker SL. _Planet Health_. Champaign, Illinois:  Human Kinetics Press, 2001.

## Goals in Creating Planet Health

**Create an interdisciplinary curriculum for middle schools that**
**Uses existing teachers**
**Reduces obesity risk by improving nutrition and activity and reducing screen time **
**Is liked by teachers and students**
**Strategy: Reducing risk based on science**

## Working with Schools

**Most children and youth are in schools**
**Schools are major settings for learning, physical activity, dietary intake**
**A caveat: strategies must be compatible with the primary educational aims of schools**

## Planet Health 

**Planet Health**** **
**Promotes...**

**Active Learning**

**Literacy Across the Curriculum**

**Notes:**
Planet Health promotes active learning, the Massachusetts Department of Education learning standards, and literacy across the curriculum.

## Behavioral Targets

**Reduce TV viewing to less than two hours per day**
**Decrease consumption of high fat/saturated fat/trans fat foods **
**Increase moderate and vigorous activity**
**Increase consumption of fruits and vegetables to five-a-day or more**

## Intervention Components

**Teacher training workshops**
**Classroom lessons (16/year) in Math, Science, Language Arts, Social Studies **
**Two-week TV reduction campaign**
**Physical Education Micro-units (30 five minute units) and Fit-checks**
**Wellness sessions for teachers  (3)**

## Effects of Planet Health

**Obesity among females in intervention schools was reduced compared to controls (OR 0.48; P=0.03)**
**Reductions in TV; both boys & girls**
**Among girls, each hour of TV => reduced obesity (OR 0.86/hour; P=0.02)**
**Increases in fruit and vegetable intake and less increment in total energy intake among girls (P=0.003 and P=0.05)**
- Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth: *Planet Health*. Archives of Pediatrics and Adolescent Medicine. 1999;153:409-18.

## Intervention Impact by School

**Females: **evidence for intervention impact in 4 of 5 schools. If the one ineffective site is dropped, intervention effect on obesity is:  OR 0.31; P=0.0002
**Males: **if the same school is dropped, intervention effect on obesity is OR 0.70; P=0.05**  **

## Change in Obesity by Ethnic Group

**Females: evidence for intervention impact by ethnic group (minimum cell size = 5)**
**Afro-American  (OR 0.14; 95% CI 0.04-0.51) **
**White (OR 0.48; 95% CI 0.20-1.13)**
**Hispanic (OR 0.38; 95% CI 0.03-5.3)  **

## Impact of Planet Health on Disordered Weight Control Behaviors: Females

**“...****girls in intervention schools were less than half as likely to report purging or using diet pills at follow-up compared with girls in control schools (odds ratio, 0.41; 95% confidence interval, 0.22-0.75).”**

- Austin SB, Field AE, Wiecha J, Peterson KE, Gortmaker SL. The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls. Arch Pediatr Adolesc Med. 2005 Mar;159(3):225-30.

## Impact of Planet Health on Delaying Menarche

**“****Girls attending an intervention school experienced menarche less frequently than girls attending control schools during the intervention period **
**   ****(RR = 0.76; 95% CI [0.66, 0.87].”**

- Chavarro JE, Peterson KE, Sobol AM, Wiecha JL, Gortmaker SL. Effects of a school-based obesity-prevention intervention on menarche (United States). Cancer Causes Control. 2005 Dec;16(10):1245-52.

## Preventive Interventions Can be Cost-Effective

**An independent economic analysis of Planet Health**
**found: **
**An estimated program cost of $14/student/year**
**Planet Health is more cost-effective than commonly accepted preventive interventions, such as screening and treatment for hypertension.**
**$4300 per QALY (quality adjusted life year)**

- Wang LY, Yang Q, Lowry R, Wechsler H. Economic analysis of a school-based obesity prevention program. Obes Res. 2003 Nov;11(11):1313-24.

## Planet Health Implementation/Dissemination 

**Expansion in Boston Public Schools via CDC, US Dept of Education, and STEPS (Boston Public Health Commission)**
**Blue Cross Blue Shield of MA has funded a four-year, $3 million program for grants to middle schools throughout MA to implement Planet Health & additional after school programming **
**5500 copies of Planet Health now distributed in 48 states and 20 countries**

## The Important Forces: 

**	****F**ood producers and the "Fast Food" 			industry - if they’re successful, we all eat 	 	more
**	****A**dvertisers for food and video/film 			industries - if they’re successful, we all buy 		more
**	****T**elevision and video/film production and 		distribution industry - if they’re successful we 	all watch more

## Thinking Outside the School: Life Course Intervention Strategies (How do we get sustained changes in reducing energy imbalance?)

**Steven Gortmaker PhD  PI**
**Charles Deutsch ScD  Co-PI**
**Jean Wiecha PhD  Co-PI**
**Multiple Community Engagement Committees**
**20 other faculty and staff**
**Funding:  Centers for Disease Control and Prevention  **

## A Broad Vision of Our Work

**It’s not just individual choice - we focus on social ecological, behavioral, and transdisciplinary approaches to improving nutrition, physical activity, and reducing overweight and chronic disease in children and youth.**
**We work with community partners to develop and evaluate interventions within multiple social and environmental settings: e.g. schools, pre-schools, after schools, primary health care, worksites, neighborhoods and homes.  Supportive change in many such environments/channels will be needed to halt the rise in chronic disease risk.  **

## Starting Young:Preventing Overweight in the Head Start Setting

- Funded by Harvard Pilgrim Health Care Foundation

## Eat Well and Keep Moving

**Evaluation indicates improved dietary intake ****	**
-    (total fat, sat fat, fruits/vegetables, vit C, & dietary fiber)
** **
** ****and Reduced Television Viewing**

**Eat Well and Keep Moving**

- Gortmaker SL, Cheung LWY, Peterson KE, Chomitz G, Cradle JH, Dart H, Fox MK, Bullock RB, Sobol AM, Colditz G, Field A, Laird N.  Archives of Pediatrics and Adolescent Medicine 1999;153:975-83.

- Cheung PLYH, Dart H, Gortmaker SL. _Eat Well and Keep and Moving_.
- Champaign, Illinois: Human Kinetics Press, 2001.

## Planet Health

**Steven Gortmaker, PhD  PI**
** ****Karen Peterson, RD, ScD  Co-PI**
**Jean Wiecha, PhD  Project Director**
**Nan Laird, PhD Co-Investigator**
**Funding NICHD HD 30780 **

- Carter J, Wiecha J, Peterson KE, Gortmaker SL. _Planet Health_. Champaign, Illinois:  Human Kinetics Press, 2001.

## Clinical Interventions in Primary Care Settings

**Maine Youth Overweight Collaborative** (lead by Maine Center for Public Health; Maine Health Access Foundation)
**Healthy Care for Healthy Kids Collaborative in Massachusetts** (lead by with National Initiative for Children’s Health Care Quality (NICHQ), with Blue Cross Blue Shield of MA)
**High Five for Kids** (lead by Department of Ambulatory Care and Prevention, Harvard Medical School (NICHD))

## Slide 50

## Slide 51

## Slide 52

##   ACTIVATE AMERICA 

_**The Gulick Project**__ _
- Directly helping individuals and families lead healthier lives

_**Community Leadership**_
**Strengthening YMCAs’ capacity for community leadership in support of healthy living**

_**Strategic Partnerships**_
**Magnifying**
**the YMCAs’ impact **
**through **
**strategic partnerships**

- Built on a solid foundation:
- A 150 year commitment to health in spirit, mind, body .

## A Vision For Ending the Obesity Epidemic and Eliminating Disparities

- We can develop interventions - grounded in science - that effectively provide supportive environments for healthy eating and physical activity for children (and adults)
- But unless this science is translated into action – into the diverse lives of households and children and youth – and via a multitude of channels, throughout the life course – the impact may be trivial.