Addressing Lifestyle Changes

Nutrition and Physical Activity (Obesity)

Colorado: Launching Colorado on the Move^TM: A Comprehensive Effort to Increase Physical Activity

Public Health Problem
Between 1987 and 2000, obesity reached epidemic proportions in the United States, with more than 45 million adults classified as obese. In Colorado, adult obesity (body mass index [BMI] > 30) rates increased from 6.9% in 1990 to 14.9% in 2001; the prevalence of overweight (BMI > 25) among adults also rose from 36.7% to 51.6% during those years.

Evidence That Prevention Works
Research has demonstrated that preventive measures such as improved nutrition, tobacco cessation, increased physical activity, and early detection and intervention may prevent heart disease, stroke, and other chronic diseases. Physical activity helps to control weight; contributes to healthy bones, muscles, and joints; reduces falls among the elderly; helps to relieve the pain of arthritis; reduces symptoms of anxiety and depression; and is associated with fewer hospitalizations, physician visits, and medications.

Program Example
Through a partnership with the University of Colorado Health Sciences, the Colorado Physical Activity and Nutrition Program is implementing two community interventions in Peetz, Colorado, which has a large rural population, and in the Denver Metro Black Churches, which allows program coordinators to work in an already established urban and African American setting to reach high-risk populations. These interventions focus on a physical activity component to encourage participants to walk 2,000 steps a day more than they walked before the program. Pedometers are offered to assist participants in their efforts. Additional worksites and community sites throughout the state are also participating. The intervention will introduce a nutrition component as well, most likely promoting a 5 A Day campaign. The program has been named Colorado on the Move^TM, and researchers at the University of Colorado plan to expand this effort beyond the currently funded program as additional money becomes available. In addition, four task forces were formed to guide the expansion of this program by assessing the burden of obesity and the impact of the other task force efforts (worksite, school, and community) to promote Colorado on the Move^TM and other initiatives.

Implications
The Colorado on the Move^TM program serves as a model for other states that are trying to encourage increased physical activity. This program demonstrates the importance of promoting community-based programs that encourage small behavioral changes over time to achieve long-term, positive health outcomes.

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Hawaii: Launching the Healthy Hawaii Initiative: A Statewide Program to Promote Physical Activity and Nutrition

Public Health Problem
According to 2001 Behavioral Risk Factor Surveillance System (BRFSS) data, 48% of adults in Hawaii do not engage in sufficient amounts of physical activity. Although more adults are active in Hawaii than in other parts of the United States, ethnic disparities are problematic; 58% of residents of Japanese and Filipino ancestry do not engage in sufficient levels of physical activity.

Evidence That Prevention Works
In 2001, the Task Force on Community Preventive Services identified six interventions that are effective in increasing physical activity levels in a community: (1) large-scale, high-intensity, community-wide campaigns with sustained visibility; (2) point-of-decision prompts encouraging people to use the stairs; (3) individually adapted health behavior change programs; (4) school-based physical education; (5) social support interventions in community settings; and (6) enhanced access to places for physical activity combined with informational outreach activities.

Program Example
In 1999, Hawaii decided to use a large portion of tobacco settlement funds on the Healthy Hawaii Initiative (HHI). HHI targets physical inactivity, tobacco use, and poor nutrition. Prominent features of HHI include school health programs, community grants, education for health professionals, and a communication campaign, “Start Living Healthy.” CDC provided technical assistance to the Hawaii Department of Health in evaluation and participated in a conference that led to the publication of Recommendations for Assessment, Monitoring, and Evaluation of Physical Activity in Hawai’i. From 2000 to 2002, the initiative funded over 40 schools and communities to implement programs and environmental and policy changes. Funded interventions include a walk to school program, a joint land use agreement between the Department of Parks and Recreation and schools, and a program to implement SPARK (Sports Play & Active Recreation for Kids) into schools’ curricula. With a 15-year time frame (1999–2014), HHI seeks to bring about environmental, policy, and programmatic changes to make long-term improvements in physical activity rates.

Implications
With adequate resources, commitment, and technical assistance, states can develop, launch, and evaluate statewide initiatives to promote physical activity. This program demonstrates the importance of collaboration between state health departments, universities, and CDC in establishing and developing a successful statewide initiative.

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Massachusetts (REACH Program): Exploring Nontraditional Approaches to Educate Special Populations About Available Health Services

Public Health Problem
Cambodians in Lowell, Massachusetts, are at a disproportionate risk for diabetes and cardiovascular disease (CVD), mainly heart disease and stroke. Among Cambodians in Lowell aged 45 or older, a disproportionate share of deaths are attributable to stroke (15.9%) and diabetes (13.4%) compared with total Massachusetts stroke (6.5%) and diabetes (2.5%) death rates. In 1999, heart disease was the leading cause of death for both Cambodian and all Massachusetts adults.

Evidence That Prevention Works
Research from several studies has demonstrated that improving nutrition, increasing physical activity, and improving access to proper preventive care can prevent or delay the progression of CVD and adverse diabetes-related outcomes such as lower-extremity amputations, kidney disease, and blindness.

Program Example
A critical part of the REACH 2010 strategy is to improve the health of racial and ethnic minority populations. The Cambodian Community Health 2010 project in Lowell, Massachusetts, targets CVD as its primary focus and diabetes as a secondary focus for Cambodian populations. During year one of the project, Community Conversations were held in seven locations throughout the Cambodian community to involve all community members in developing the action plan. The Community Action Plan combines strategies focusing on the Cambodian community and its leaders, the health care system and medical providers, and public health research. Strategies to reach community members included organizing a “walking meditation” trip through a Buddhist temple, conducting weekly Tai Chi classes, promoting medical interpreter services, and conducting a behavioral risk factor survey adapted for Cambodians. A Cambodian Elders’ Council also was formed to give a voice to older Cambodian refugees who often are homebound and isolated because of language barriers. Learning tours were also conducted to familiarize Cambodians with emergency services and related facilities such as police stations, hospitals, and city hall. Fruit and vegetable picking trips gave participants an opportunity to focus on nutrition, and health education classes, including smoking cessation instruction, were conducted in English as a Second Language classes.

Implications
This program demonstrates the importance of collaborating with community members and using culturally appropriate and innovative strategies to extend health education and services to special populations.

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Michigan: Providing Disease Prevention Services and Athletic Shoes to Low-Income Women Through the WISEWOMAN Program

Public Health Problem
Cardiovascular disease (CVD), mainly heart disease and stroke, is the leading cause of death in the United States and the number one health threat to women in Michigan. Improving nutrition and physical activity to reduce cardiovascular disease risk factors can be particularly challenging for low-income women, who typically have limited access to fitness centers, nutrition counseling, transportation, or fitness equipment.

Evidence That Prevention Works
Research has demonstrated that preventive measures such as improved nutrition, increased physical activity, and early detection and intervention can prevent heart disease and stroke and improve the health of women who already have CVD. In addition, the University of South Carolina Prevention Research Center found that reducing barriers to exercise increases the likelihood that people will engage in physical activity.

Program Example
WISEWOMAN programs provide additional preventive services to women participating in the National Breast and Cervical Cancer Early Detection Program. States use this established system and other partnerships to screen women for risk factors for heart disease and other chronic diseases, conduct nutrition and physical activity interventions, and provide referrals for medical care and smoking cessation as needed. In Michigan, WISEWOMAN staff used funds made available through the Lansing Area League of Women Voters to buy athletic shoes for low-income program participants. WISEWOMAN staff also partnered with a conveniently located store that carries athletic shoes to allow selected participants to receive a quality pair of shoes through a discount and $30 gift certificate combination. Each recipient was required to meet with a lifestyle counselor to set goals and complete a lifestyle contract. By eliminating one important barrier to physical activity (lack of appropriate equipment), the Ingham County Health Department helps WISEWOMAN participants to lead healthier lives.

Implications
Screening and lifestyle interventions that reduce barriers can improve the health of low-income women. The WISEWOMAN program demonstrates the importance of working with nontraditional partners to increase resources to help low-income participants reduce their risk for cardiovascular disease.

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North Carolina: Promoting a Childhood Healthy Weight Initiative by Improving Nutrition and Physical Activity

Public Health Problem
The percentage of children who are overweight in the United States doubled during the past two decades, and the percentage among adolescents almost tripled. Data from the North Carolina Nutrition and Physical Activity Surveillance System show an even greater increase in the state. Between 1995 and 2000, the prevalence of overweight increased by 36% in preschool children, 40% in school-aged children, and 14% in adolescents.

Evidence That Prevention Works
Research has demonstrated that preventive measures such as improved nutrition, tobacco cessation, increased physical activity, and early detection and intervention may prevent heart disease, stroke, and other chronic diseases. Healthy eating behaviors lower the risk for many chronic diseases, including obesity, heart disease, stroke, some types of cancer, diabetes, and osteoporosis. By establishing healthy eating and physical activity habits early in life, children are more likely to carry these habits into adulthood.

Program Example
The North Carolina Healthy Weight Initiative is the coordinating group for issues related to healthy weight, nutrition, and physical activity for the state’s children. Through this initiative, North Carolina developed a comprehensive state plan focused on children aged 2–18 years. The North Carolina initiative is enhancing the state’s pediatric nutrition surveillance system and is implementing programs designed to improve the nutrition and physical activity behaviors of young children and their families. Launched in the fall of 2002, the plan, Moving Our Children Toward a Healthy Weight: Finding the Will and the Way, calls for a multilevel approach to reducing the number of overweight and obese children. It focuses not only on behavioral and interpersonal change, but also on the organizational, community, and societal changes necessary to support healthy eating habits and increased physical activity for children, teens, and their families. North Carolina is also enhancing its pediatric nutrition surveillance system to better monitor trends in body mass index and selected dietary and physical activity behaviors. In addition, a pilot intervention in eight counties throughout the state targets children aged 2–5 who are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or the Child and Adult Care Food Program. This program uses policy, environmental interventions, and educational programs to reach staff members and families with important health messages.

Implications
The North Carolina initiative uses strong partnerships to enhance the state’s overall capacity to mobilize nutrition and physical activity promotion efforts and reduce the number of children who are overweight. This program demonstrates the importance of a coordinated approach, which entails collaboration among partners both internal and external to the North Carolina Division of Public Health.

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Texas (REACH Program): Training Peer Educators and Advocates for Health: The REACH Promotora Community Coalition

Public Health Problem
Compared with rates among whites, rates of diagnosed diabetes are 2.5 times higher among American Indians and Alaska Natives, 2.0 times higher among African Americans, and 1.8 times higher among Hispanics. The Texas Department of Health estimates that more than 1.3 million Texans aged 18 years or older have diabetes. About 911,000 of these, 6% of the state’s population, have been diagnosed; the remainder are not aware they have the disease.

Evidence That Prevention Works
In the United States, diabetes is the leading cause of new cases of blindness, lower-extremity amputations, and kidney failure. These serious outcomes can be prevented or substantially delayed through regular screening, appropriate care that includes long-term follow-up, and behavior modification.

Program Example
The REACH Promotora Community Coalition, led by Migrant Health Promotion, has developed a program to address diabetes along the border of Texas and Mexico. The coalition targets communities in Hidalgo and Cameron counties, which are more than 80% Mexican American and have some of the lowest socioeconomic indicators, with more than 35% of their residents living below the poverty line. Developing the full potential of the community health workers (promotoras) is key to this program. The promotoras not only serve the community as health educators and advocates, but also are trained to become community leaders as they gain experience as community organizers, program planners, and program evaluators. The target population lives in colonias, which are communities with little infrastructure. Therefore, it is vital to use existing institutions such as public schools, community health clinics, and community-based organizations to reach this population. Also, because many adults lack access to transportation or telephones, much of the work is conducted through home visits and neighborhood meetings. As a result of the Migrant Health Promotion project, school health teams have been created to assess existing nutritional choices and opportunities for physical activity in schools and suggest measures to improve these choices and opportunities at school and at home.

Implications
By using community-based health advisors to promote behavior change along with an evaluation component to document and assess their contributions, the Migrant Health Promotion project lends credibility to diabetes prevention interventions. This community-based approach can extend lifesaving prevention programs and health services across cultural divides to communities that would not likely be reached by traditional means.

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Washington: Promoting KidsWalk-to-School Day: A Program to Promote Physical Activity and Pedestrian Safety

Public Health Problem
In the United States, only about 1 of every 10 trips to school is made by walking or bicycling. Of school trips 1 mile or less, only 31% are made by walking, and within 2 miles of school, just 2% are made by bicycling. Research suggests that the decline in walking and bicycling may be contributing to the number of overweight children, and in Washington, the number of overweight children has doubled between 1980 and 1999.

Evidence That Prevention Works
Immediate health benefits of regular physical activity for children include building and maintaining healthy bones, muscles, and joints; controlling weight and reducing fat; fostering healthy social and emotional development; and improving academic performance.

Program Example
To increase opportunities for children to engage in physical activity, Washington State has promoted KidsWalk-to-School Day and the creation of safe walking routes for children to raise awareness about the importance of walking to school. The Washington Coalition for the Promotion of Physical Activity (WCPPA) and the Oregon Coalition for the Promotion of Physical Activity (OCPPA) collaborated to develop a KidsWalk-to-School Day packet of materials that included the Walkability Checklist, the Neighborhood Walking Safety Guide, CDC’s KidsWalk-to-School Guide, a list of related educational Web sites, and a Safe and Active Routes to School presentation on CD-ROM. This packet was distributed to community leaders who are interested in promoting walk-to-school efforts. One of the best examples of community involvement in KidsWalk-to-School Day in Washington is in Kitsap County. The Kitsap County Health District solicited help from a broad array of partners including the American Red Cross, Washington State Traffic Safety Commission, Kitsap County Commission for Children and Youth, Parent Teacher Association (PTA), Kitsap Safe Kids Coalition, Kitsap Community Federal Credit Union, Naval Hospital Bremerton, and representatives from local school districts. About 3,500 children at seven schools and many parents participated in KidsWalk-to-School Day.

Implications
The KidsWalk-to-School program encourages physical activity as an integral part of a child’s daily routine. This program demonstrates the importance of promoting walking and bicycling to school to help increase the likelihood that children will engage in physical activity and carry this habit into adulthood. In addition, KidsWalk-to-School promotes the development of safe walking and bicycling routes and safe pedestrian practices to potentially reduce injury among children.

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