Developing a Strategy Menu for Community-Level Obesity Prevention

Abstract

Importance

Childhood obesity is a complex problem influenced by policies, systems, and environments across multiple settings. The prevention of childhood obesity requires changes across a range of community settings.

Objective

To describe the development of an obesity prevention strategy menu that incorporates effective policy, systems, and environmental changes for reducing and preventing childhood obesity, and which offers the flexibility to consider local community needs and capacity.

Methods

We describe the development of a strategy menu and some of the challenges of this process. We then elaborate on how communities will interact with the strategy menu and the development of a website to facilitate this interaction.

Results

No single discipline has all of the expertise needed to identify strategies for childhood obesity prevention. Therefore, a multidisciplinary team of researchers and practitioners reviewed evidence and organized a menu that assists communities in choosing complementary strategies tailored for efficacy in specific community settings. The strategies will eventually be part of a web-based point of access that complements the foundational relationships built between communities, researchers, and practitioners.

Conclusions and Relevance

The strategy menu is comprised of a set of effective approaches that communities can use to develop tailored, context-specific health interventions. By developing a framework to engage communities in the selection and implementation of multi-setting obesity prevention strategies, we aim to create and sustain momentum toward a long-term reduction in obesity in Wisconsin children.

Introduction

The Obesity Prevention Initiative in Wisconsin is piloting a multi-setting community intervention study for childhood obesity as one of three components of the larger initiative described in this issue by Adams and colleagues.¹ As an initial step, a team of University of Wisconsin researchers, community members, and practitioners (the intervention team) are conducting a pilot study using comprehensive community prevention strategies in two Wisconsin counties, Marathon and Menominee.² Herein, we present two aspects of this pilot study.

First, the intervention team, supported by a national advisory group of obesity prevention experts, has developed a menu of multi-setting, evidence-based strategies (strategy menu) to address obesity. To do this, the team focused on identifying environmental and policy-related obesity prevention strategies that can be tailored to specific Wisconsin community needs and contexts. Second, the intervention team is working with the two initial communities in an ongoing study to pilot the strategy menu along with providing technical support for implementation. Through a process of local capacity building, along with academic support for community-based participatory research, outreach, and surveillance, the initiative will engage Wisconsin citizens in making policy, systems, and environmental changes at both the grass roots and institutional levels.¹ While this article focuses on the strategy menu, selection framework, and local implementation, the article by Christens and colleagues in this issue describes the engagement component in more detail.³

The approach taken by the Obesity Prevention Initiative started with the acknowledgement that there is no “silver bullet” for reducing childhood obesity. The intervention team grounded its work in the social ecological model of health, a theoretical framework for understanding the multiple factors that influence health and wellness of individuals, groups, and populations. The complex challenges of childhood obesity prevention cannot be addressed through clinical care and education alone.⁴ Rather, a collaborative, multi-setting approach that includes policy, systems, and environmental prevention strategies is vital. Such an approach also needs to be flexible and responsive to community needs rather than a top-down prescription for change. This article describes the development of the obesity prevention strategy menu, how pilot communities are using the menu, and future development of a web-based point of access for community technical assistance and resources.

Strategy Menu Development

Previous initiatives have shown that community-wide capacity-building followed by the implementation of multiple strategies across settings, is one of the promising approaches for obesity prevention initiatives.^5–8 This approach can influence individuals from diverse directions and extend reach to different groups within a community, but does come with challenges. The first and foremost is: how do we provide an evidence-based foundation and the associated technical support to Wisconsin communities that differ in context, capacity, and resources? To answer this question, we identified four important steps: leveraging expertise from multiple disciplines, identifying and synthesizing evidence for multi-setting interventions, creating a menu of strategies, and providing information and technical assistance to help communities select strategies that will be effective within their specific context.

Transdisciplinary Approach

Recognizing that that no single discipline had all of the necessary expertise to identify potential obesity prevention strategies, the Obesity Prevention Initiative followed the lead of other transdisciplinary research programs in public health like the Center for Training and Research Translation at the University of North Carolina at Chapel Hill.⁹ The intervention team included researchers and practitioners from nutritional sciences, urban and regional planning, landscape architecture, food systems, pediatrics, family medicine, public health, and community development, who collaboratively developed the initial menu for community feedback. Development reflected key aspects of other transdisciplinary initiatives by bringing together multiple perspectives on methodologies, theories, and working strategies.^1,10 A unique aspect of the Obesity Prevention Initiative’s approach has been the ongoing involvement of community partners and practitioners in identifying strategies. These partnerships have been supported by the work of healthTIDE staff members.¹¹

Public health researchers and practitioners are increasingly recognizing the importance of people’s environments in supporting or hindering health efforts as well as the necessity for community leadership in sustaining health promotion related-activities.¹² Our approach seeks to mobilize communities in pursuit of policy, systems, and environmental changes that can catalyze healthy behaviors and positive outcomes. In this way, our approach is aimed at primary prevention through school food policies, transportation policies, access to affordable healthy food, land use policies and other policy, systems, and environmental changes.

Identifying and Synthesizing Evidence for Multi-Setting Strategies

The intervention team reviewed existing resources, including What Works For Health Wisconsin (What Works), the US Department of Health and Human Services Guide to Community Preventive Services (the Guide), the CDC recommended community strategies to prevent obesity, and others.^13–15 In cases where existing reviews from those resources were older, disciplinary experts on the team searched for newer studies. The team also examined systematic reviews and individual studies for various settings (schools and early childhood environments, the built environment, worksites, health and maternal care and others) to identify strategies not included in What Works or other existing resources.

A specific challenge of the transdisciplinary approach is that different disciplines (and even researchers within the same disciplines) have different evidentiary standards. Also, population-level changes have not typically been studied using the designs that have been used in efficacy trials or behavioral interventions for clinical preventive services and medical care.^13,16 Therefore, the team developed a protocol for review of population-level environmental and policy-related health interventions based on that used in the Guide.^13,16,17 This protocol evaluates a variety of factors to determine the strength of evidence for an intervention, such as study execution, design, and the weight of expert opinion. Based on these reviews, the strength of evidence for an intervention is labeled as “strong”, “sufficient”, or “expert opinion”. The recommendation reflects the confidence by the reviewers that changes in outcomes, such as increases in physical activity or consumption of fruits and vegetables, are attributable to the intervention and not to other factors. The categories of “strong” and “sufficient” evidence are determined based on either a small number of available studies with better execution and more suitable design, or a larger number of studies with less suitable design or weaker execution. The “expert opinion” category is used when the intervention is in widespread use or important enough to consider, but there are too few studies or other evidence is not available. Examples of these categories assigned to specific strategies can be found in Table 1.

Table 1.

Example Summary Table for Comparing Strategies

Strategy	Likely Effect Size1	Immediacy2	Sustainability3	Evidence	PSE or Program
1.1: Complete Streets	2	1	3	Strong	Policy/ Envir.
1.2: Safe Routes to School	2	2	1	Strong	Program
1.3: Complete bike path networks	2	1	3	Strong	Envir./ Program
1.4: Public transit	2	1	3	Strong	Policy/ Envir.

¹Effect size is the measure of the strength or size of the potential results of a strategy. The scale for effect size ranges from 1 (weakest) to 3 (strongest). Scores are assigned based on evidence of effectiveness in the scientific literature or through expert opinion.

²Immediacy is the amount of time for a strategy to be fully implemented to the point where effects can be measured. The scale for immediacy ranges from 1 for a longer amount of time to 3 for a shorter amount of time. Scores are assigned based on evidence of immediacy in the scientific literature or through expert opinion.

³Sustainability is the long-term viability of a strategy. The scale for sustainability ranges from 1 when a strategy is unlikely to continue without long-term investments of money and resources to 3 for when little to no consistent investment of money and resources will be required to support the strategy. Scores are assigned based on evidence of sustainability in the scientific literature or expert opinion.

Strategy Menu Design

To address the challenge of organizing strategies that cut across settings or differ in scope or structure, the intervention team clustered the most promising strategies into nine inclusive nutrition, physical activity, health care, and maternal care approaches. In addition to encompassing the evidence base, approaches are designed to align with work being done by other Wisconsin organizations such as the Wisconsin Department of Health Services. Within each approach are three-to-five promising obesity prevention strategies for environmental or policy-related changes to promote healthy eating and physical activity in key settings, including schools, homes, childcare centers, healthcare organizations, worksites, and neighborhoods. While the focus of the Obesity Prevention Initiative is on childhood obesity, the intervention team recognized that to be successful, it is important to provide strategies benefiting all community members, because the health behaviors of children are strongly influenced by those of adults within their homes and communities.⁵ Box 1 lists menu approaches and strategies.

Each strategy includes information to help communities make informed decisions. Key details on likely effect size, immediacy, sustainability, and strength of evidence of effectiveness are displayed in the example in Table 1. The scale for effect size, immediacy and sustainability ranges from one (weakest) to three (strongest). For example, of the four active transportation strategies listed, complete streets policies and projects are estimated to have a moderate effect size, a low level of immediacy (greater than three years to implement), and a high level of sustainability. Because no single strategy, when implemented alone, is likely to strongly impact childhood obesity at the population level, the Obesity Prevention Initiative encourages communities to implement a mix of programs, policies, and environmental changes.^18,19 For example, a Complete Streets project might be paired with a Safe Routes to School program to ensure that neighborhoods near schools have walkable streets. Implementing strategies across multiple settings is most likely to result in population-level changes in overweight and obesity.

Using the Strategy Menu

Many Wisconsin communities are already implementing obesity prevention interventions and have expert knowledge of previous successes and challenges. As a key step in selecting and implementing strategies, communities are encouraged to inventory assets (e.g. local champions, health coalitions) and barriers (e.g. vested interests, land use policies that enable urban sprawl). The Obesity Prevention Initiative envisions communities using the menu to create a tailored set of obesity prevention strategies that takes into account past and present public health interventions, as well as current needs and priorities.

In Wisconsin, community context varies widely across the state for a number of demographic, cultural, and physical features (e.g. ethnicity, population densities, cultural traditions, land use types, topography, transportation infrastructure). Assessing community context is an important step in determining which strategies are feasible and which are likely to be most effective for the local social, economic, and environmental conditions.¹⁸ The rural to urban transect model is an example of a tool that can help communities understand the importance of context in selecting strategies to improve mobility and physical activity within the built environment (see Figure 1).²⁰ For instance, enhancing a public transit system may be an appropriate strategy for an urban setting, but may not be feasible in less populated areas. Similarly, a regional bike trail system may be a more appropriate strategy to increase physical activity along rural roads than adding sidewalks. Another important contextual consideration is how winter months impact physical activity and food consumption in regions that experience cold winters. Some communities may need to winterize physical activity or nutrition strategies to increase their benefits (e.g., creating multi-use bike and cross-country ski trails).

Figure 1. Rural-to-Urban Continuum.

Rural: Photo by James Van Hemert (CC BY-NC 4.0) Copyright 2003 American Planning Association. Suburban: Photo by Sylvia Lewis (CC BY-NC 4.0) Copyright 2008 American Planning Association. Urban: Photo by Carolyn Torma (CC BY-NC 4.0) Copyright 2015 American Planning Association. Aerial imagery: © Copyright Digital Globe. Landsat, U.S. Geological Survey. USDA Farm Service Agency. Map data © Google.

Future Work

The Obesity Prevention Initiative intervention team is developing an interactive website that includes strategy summaries, evidence, links to resources and assessment tools, suggested complimentary strategies, and a scoring system for comparing strategies. The site will also provide Wisconsin examples of implementation and allow communities to search for specific topic areas or settings. While it will provide a collective point of access for technical assistance, the website is not intended to replace the foundational relationships built between communities, experts, and practitioners. After continued testing and refinement, this tool will be useful to communities, scholars, and practitioners. Future iterations may expand its use beyond Wisconsin.

Conclusion

A transdisciplinary approach to obesity prevention, while vital to making progress in obesity prevention, can be challenging due in part to different disciplines having different evidentiary standards for effective strategies. To address this, the intervention team of the Obesity Prevention Initiative has developed a strategy menu that encompasses important elements of various disciplines and provides evidence that has been systematically reviewed so that communities can choose from strategies likely to be effective in preventing childhood obesity. These strategies are clustered into nine approaches, and are inclusive of nutrition, physical activity, health care, and maternal care approaches.

Throughout the process of developing this menu, the intervention team has strived to balance strength of evidence with expert opinion and on-the-ground practice in Wisconsin communities. Practitioner feedback indicated that some promising strategies are hard to achieve in the context of particular communities and that smaller steps are sometimes easier. This kind of understanding is only available once engagement with communities is ongoing. For this reason, the intervention team not only considered strategies supported by scientific research and a rigorous evidence base, but also strategies that have demonstrated positive results based on practice-based evidence.²¹

The strategy menu developed as part of the larger Obesity Prevention Initiative will serve as a tool that communities can use to shift momentum toward a long-term reduction in obesity prevalence in children and adolescents. Ultimately, both policy and environmental changes will promote improved nutrition and physical activity behavior, which will, in turn, decrease childhood obesity.

Box 1. Approaches and Strategies.

• Approach 1. Active Transportation

  1. Complete Streets
  2. Safe Routes to School
  3. Complete Bike Path Networks
  4. Public Transit
• Approach 2. Recreational Spaces and Programming

  1. Access to Places for Physical Activity
  2. Parks and Open Space
  3. Recreational and Community Fitness Programs
• Approach 3. Active Settings

  1. Active Time in Schools and Early Childcare Environments
  2. Workplace Wellness Initiatives
  3. Physical Activity Policies
• Approach 4. Community Design For Healthy Living

  1. Mixed-use Development
  2. Public Infrastructure
  3. Comprehensive Planning
• Approach 5. Healthy Food Access and Consumption

  1. School Wellness Policies
  2. Healthy Food Standards in Public Places
  3. Healthy Food Procurement
  4. Early Care Nutrition Policies
  5. Healthy Food Standards in Hospitals
• Approach 6. Local Food Economies and Agriculture

  1. Access to Locally Produced Food
  2. Local Food Production, Processing, and Distribution
  3. Farm-to-Institution
  4. School Gardens
  5. Community Farms and Gardens
• Approach 7. Food and Beverage Industry Change

  1. Food Store Incentive and Recognition Programs
  2. Healthy Food Stores in Underserved Areas
  3. Restaurant Menu Labeling
• Approach 8. Breastfeeding and Maternal Care Practices

  1. Breastfeeding Friendly Maternity Care
  2. Breastfeeding Friendly Workplaces
  3. Breastfeeding Friendly Childcare
  4. Breastfeeding Friendly Public Spaces
  5. Healthy Lifestyles for Mothers
• Approach 9. Clinical Care Practices

  1. BMI Screening
  2. Team-based Obesity Care
  3. Provider Education, Training, and Resources
  4. Patient Self-management and Counseling