Preventing Childhood Obesity Through Healthy Communities

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: giving children with obesity a chance to play more, eat better, and get healthy.

DR. TERRY O'TOOLE:
Addressing obesity is not a single-shot strategy. It's going to really take collaboration between the public health sectors and other sectors such as businesses and transportation.

DR. JOHN DREYZEHNER:
Even though we started moving to do this, I don't think I fully appreciated it until we actually started doing these grants why this was so important.

DR. JOHN VICK:
We felt like this might be a harder sell than it really has been. I think the communities really get it.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

Today, we focus on the fight to save a generation of children living with obesity, and the notion that their environment must change before their health will improve.

Almost 19% of America's children meet the qualifications for obesity, a condition whose impacts are far reaching. There are numerous health concerns, but also social conditions like depression stem from being overweight.

We'll introduce you to three advocates working on this problem at the national and state level.

Dr. John Dreyzehner and Dr. John Vick are leading a team that's changing the rules of the game in their home state of Tennessee. We'll find out what they're doing and how it's working.

But first, our conversation with Dr. Terry O'Toole, chief of the Program Development and Evaluation Branch in the Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention in Atlanta. He's been working on this issue for a good part of his career. His assessment is overwhelming, but so is his optimism.

O'TOOLE:
Well, unfortunately, the rates of obesity are still climbing. Obesity is very common in America, it's also quite dangerous and quite costly.

Actually, according to our—the CDC's—latest national data, almost 19% of children ages 2–19 have obesity. This amounts to nearly 14 million youth, or about one in five of our children. Unfortunately, obesity also affects an alarming number of adults; one in three adults have obesity, putting people at risk for diseases such as diabetes, heart disease, and certain cancers.

And I said, this is dangerous. And the reason I say that is because if we look at the weight standards required to join the military, nearly one in four young adults do not meet the weight standards that are required to the join the military. So, this can put us at risk in other ways that they might not initially imagine with the consequences of obesity.

I said it was costly. Obesity also costs the U.S. healthcare system about $147 billion—with a B—a year. And, as I mentioned, that impacts our economic system as well. We also see that our country spends $117 billion—with a B—on healthcare costs that are associated with some of the risk factors that are associated with obesity; in this case, $117 billion on healthcare related to inadequate physical activity.

And so, it's important for us as a nation, as states, as communities, to take a look at the problem of obesity and do what we can to address those.

JOHNSON:
What is the solution? You've been working on this for a long time—where are we headed?

O'TOOLE:
Well, we certainly know that children with obesity, they face a lot of health problems both in the short- and long-term ranging from chronic disease to other health concerns—this includes bullying by their peers and low self-esteem. As I mentioned, children with obesity are at high risk for other chronic diseases such as asthma, bone and joint problems, and type two diabetes.

So, some of the solutions that we know work are important for us to consider. We know that there's not one simple solution to address the high levels of obesity in the United States. In fact, it'll take all of us working together. It takes a societal effort.

At CDC, we have three proven strategies where we ask community leaders, policy makers, employers, school personnel, government workers, childcare and healthcare professionals, and many others to help to create places that make it easier for adults and families to be more physically active, to move more, and to eat better. Some of these solutions involve the choices that we have in our communities.

We know that at the individual level—individual habits and behaviors—are influenced by our family, by caregivers, by peers, by organizations and communities. And we also know, Robert, that many communities in states across the United States don't have the supports in place that encourage healthy eating and active living.

In fact, before I get into some of those solutions, if I might, I'd like to share just a couple of challenges communities face. We know that nearly 30 million Americans live in neighborhoods without easy access to affordable, nutritious food. We also know that only 39% of the U.S. population lives within walking distance of a park.

We've heard a lot of the news lately about the struggles and challenges with regard to residents in rural America. And we know that residents in rural communities and some racial/ethnic groups have less access to healthy foods and fewer opportunities to be physically active compared to members of other groups and communities.

And so, as I said earlier, we know what works at CDC. We have three proven strategies that we encourage states and communities who really have an important role in supporting all Americans across the lifespan to eat healthy and be active.

JOHNSON:
Can you give us some specifics?

O'TOOLE:
One of the things that we're asking folks to do is to collaborate with partners to connect sidewalks, paths, bike routes, with public transit, with where we live, work, and play. With schools—you know, you may have heard of the walk-to-school program or a safe-routes-to-school program. These are actions that schools and communities and work sites can take to make their community safer for folks to bike, to walk, to ride, to roll to where they live and work. That's one on the physical activity side.

Another strategy that we have asked folks to do is to work to improve access to healthy foods. We do this by asking folks to take a look at the foods that are available in their community settings, in their work sites, in schools, and are they healthy foods offered? Are there standards for those foods so that our kids can have access to healthy foods? So that employers—when they have vending machines, when they have concessions, when they have cafeterias—that they're offering healthy foods, so that employees can actually eat a healthy meal while they're at work. Because we know that healthy students learn better. Healthy employees have less absenteeism and have lower healthcare costs.

JOHNSON:
With your Active People Healthy Nation campaign, the goal I read was 27 million Americans by 2027 getting more physically active. Do you think that's a realistic goal? I mean, that's about 10 years from now, just a little bit less than that. How did you come to that goal and what is it going to take to actually reach it?

O'TOOLE:
You hit the nail on the head that the strategy that we're promoting, this initiative to get 27 million Americans more active by 2027. We know that the data that we have indicate that we need more Americans getting off the sofa and walking more, keeping more active, having opportunities even through the workday to be more active with initiatives such as standing workstations or walking programs, and the like.

Addressing obesity is not a single shot strategy. It's going to really take collaboration between the public health sectors and other sectors such as businesses and transportation. So, it's important for us if we're going to improve physical activity, we've really got to establish those active communities.

JOHNSON:
What are some of the stories and reports you're getting back from the field?

O'TOOLE:
Yes. We've got several examples that we can share of how folks are connecting activity-friendly routes with everyday destinations.

For example, here in Atlanta, Georgia, we have the BeltLine; and the BeltLine is converting abandoned railway into a combination of trails, parks, light rail transit, high density residential buildings, and commercial development. This covers up to 22 miles of pathway so that Atlantans can roll, ride, or walk, connecting neighborhoods with restaurants and schools and parks.

Another example is in Houghton, Michigan. They actually improved public access to their waterfront—and it's a remote city in the upper peninsula of Michigan—and they acquired a stretch of shoreline property and they replaced their industrial ruins with parks, marinas, and paved bicycle and pedestrian trails, which now connect the city center to parks and residential districts.

And so, that's the point of connecting activity-friendly routes to everyday destination. An activity-friendly route is one that is a direct and convenient connection with everyday destinations that offer protection from cars, making it easier to cross the street, for example, and connecting that route to every destination, that is to say, everyday destinations like grocery stores, schools, where we work, libraries, parks, and restaurants. And that really will help us meet our goal of 27 million Americans become more physically active by 2027.

JOHNSON:
What would you say are the stakes in this fight?

O'TOOLE:
Obesity is all too common, dangerous, and quite costly, Robert. I think those are the stakes we're fighting for. We know that seven of the top 10 leading causes of death in the United States are from chronic diseases. These are diseases that we can prevent.

JOHNSON:
States are invited to join one of CDC's technical assistance calls to hear what's working for public health practitioners around the country and to make new connections. For more information, visit cdc.gov and search "obesity" for contact numbers. The link also can be found in the show notes for this episode.

Across Tennessee, work is underway to change the lives of children dealing with obesity one park playground and farmer's market at a time. The state, for the last couple of years, has used small dollar grants to build opportunities for exercise and improve access to fresh foods.

Dr. John Dreyzehner is Tennessee's commissioner of health. When asked what the state can do to help children, Dr. Dreyzehner answers first with the reminder from the annals of public health history.

DREYZEHNER:
Well, I think back to the 1850s and Dr. John Snow—the father of epidemiology—was facing a cholera epidemic in London in Soho at 1854; and didn't have germ theory so, you know, didn't know precisely what caused cholera. But that didn't stop him from doing an analysis and mapping out where the cases were clustering, and ultimately taking the handle off of a pump that was the source of what we now know was a microbe that was causing cholera in the population.

So, by analogy, we have this epidemic of chronic diseases that are rooted in the big four: excess of caloric intake being one of those, lack of physical activity being another. And we can absolutely do some things, even if we don't understand all of the root causes.

We can absolutely do some things to impact our environment and our communities to make those things less likely. So, you know, things like working hard to assure that the healthy choices are both the easier choices and more rewarding choices, particularly focusing on physical activity programs and opportunities for children in the school and even before they hit school age.

JOHNSON:
Talk about your built environment grant program. What were you thinking when you started it?

DREYZEHNER:
Even though, you know, we started moving to do this, I don't think I fully appreciated until we actually started doing these grants why this was so important. You know, we thought that, you know, facilitating communities obtaining grants for built environment purposes was a great activity for public health to do, and we did that.

But when we started funding it ourselves, something fundamentally changed; and that was that the people that we are providing grant dollars for from the first really starting to think about how do we improve health in our community? Rather than how do we get a running track funded, or how do we rehabilitate space to accommodate more of physical activity for kids, or how do we place a park in our community, the first question was, “How do we improve health in our community through the built environment?” 'Cause that's really what we were asking as a part of the grant, and that's a different conversation.

And it also started spurring a lot more activity around. You know, you would see a small project either be gone or completed, and that would spur other projects that weren't necessarily—we weren't funding them. But now, all the other things that they were thinking about were about how do we improve health and community. And the fact that public health has been a funder not only gives us a seat at the table, but more importantly, gets the grantees thinking about how they improve health in their community; and that that in and of itself is important, and it must be important to health because public health is funding it.

So, I look forward to the evaluation that we doi. We're, as I said, you know, we've been doing this for a couple of years in all of our counties, but we're still in the early stages of really understanding how, you know, what the overall impact of that has been. We can look at process measures, like the numbers of run clubs and the various types of projects that we funded, but we need to really start getting to how's it affecting the health of the population.

JOHNSON:
Well, I'm from a small town; and I know in a small town, a new playground can be a big deal in and of itself. When you attach this message to it, it sounds like you're having more impact than you even thought.

DREYZEHNER:
Having much more impact than I even thought. Like I said, it was—it changes the conversation from what can we do to make our community a nicer place or more attractive, to what can we do to make our community healthier. And when you have mayors and town council members, and—at the county—commission members, you have that kind of leadership thinking about that specifically, that's a game changer.

JOHNSON:
So, exactly how does Tennessee’s program work? For that answer, we checked in with Dr. John Vick, evaluation and assessment director within the Office of Primary Prevention, also at the Tennessee Department of Health.

VICK:
And so, we offer two different grant programs across Tennessee. One of those is a non-competitive program and we offer $10,000 to every one of our county health departments in the rural areas. So, we have a bricks and mortar health department in each of our 95 counties: the metros operate their own health departments, there are six of those; and then, the other 89 counties are operated by the Tennessee Department of Health.

And so, we offered $10,000 to each of those 89 rural counties for built environment work. And we said, "This is a priority for our department. This is something that we want you to think about, and we want to provide some funding for a project that maybe you have in mind, or this can enhance something else that's happening in your community. But we want to provide some funding to give you the opportunity to help increase access to publicly available health promoting infrastructure."

And so, we offered those grants to all of the counties, and it funded a number of different types of projects: anything from walking trails to walking tracks, playground equipment, enhancing existing infrastructure like greenways but maybe adding things like lighting or benches or seating. One project funded a new bike share at a community center.

So, a lot of different kinds of projects. And we really wanted to leave it open to give communities the opportunity to be creative and to figure out what they needed in their community so that people could be more active, and what are the best ways for that community to promote a healthier lifestyle? So, we fund work in that way.

We also have a recently launched competitive built environment grant program. This is the Access to Health Through Healthy Active Built Environments grant program. And this offered $85,000 to any a local governments or non-profits across the state to fund either assessments, programming, construction, or planning for healthy, active built environments.

And those grants are just now beginning in 2018, and they're funding a number of different types of projects. That's a little bit more money than we offered with the non-competitive grants. So, that money is funding some larger projects: it's creating farmer's markets or small parks or new sections of greenway or sidewalks.

So, we've been able to offer a little bit more money to build additional healthy infrastructure in communities, and we have awarded 34 of those grants across the state.

JOHNSON:
And I don't think most people believe that health departments are out there engaging in the infrastructure conversation daily, but that's what you're doing.

VICK:
We are, yes, and I think that's critical. You know, in public health, when we think more broadly about what impacts our health, we know now that your zip code is more important predictor of your health than your genetic code. We know that place matters and influences our health. And so we, as a public health department, really have to think critically about the work that we're doing and we have to think about how we can move farther upstream, how we can take a more primary prevention approach to addressing our health issues. And one of those ways is to engage in other sectors work and to engage other sectors, to think about how their decisions that are impacting health.

So, in many ways in public health, we are trying to treat people who are getting sick as a result of the decisions that are made by other sectors. We in public health don't make transportation policy, we don't build roads, we don't build parks, we don't make housing policy. And so, how can we engage those sectors to help them realize how their decisions are impacting the health of communities and how can we work together to try to improve that?

JOHNSON:
You've been at this about two years. What kind of reaction are you getting from the communities where these programs are rolling out? Is anyone saying to you, "Hey, that's not your lane"?

VICK:
So, I think in general the feedback that we've gotten from communities has been really positive—in fact, in many ways, surprisingly positive. I think that we felt like this might be a harder sell than it really has been. I think the communities really get it. I think when you go out to a rural or suburban community and you say, you know, "Where can you go to be physically active? Where can you go to get healthy food," they understand that there are a number of opportunities to improve those things and may, in many cases, know exactly what those opportunities are.

I think they have not had an ally within the public health field in their community who could help to coordinate those efforts. I think there's a realization of the importance of it, and I think that they know that it's important and they're just looking for ways to engage. And so, I think our department and certainly our Healthy Development coordinators provide that opportunity.

JOHNSON:
On the grant side of the equation, is this a one-time shot or do you anticipate having additional rounds of grants in the years ahead?

VICK:
We do anticipate having additional rounds of grants in the years ahead. I do feel like our two grant programs that we've administered so far have been a test to see how they are received and to see if they are resulting in the kinds of changes to our environment that that are health promoting and that are making a difference. And we want to see how well received they are by the communities.

And we want to see if we maybe need to tweak things; because again, this is very new for us, and there's not a lot of precedent for how to do this kind of work as a public health department. And so, we're trying something. We're trying something and we're gonna learn from it and we're going to build off of it.

JOHNSON:
How do you determine the impact of a walking trail on public health?

VICK:
So, it's very challenging and it's challenging in the sense that many of the health outcomes that we're trying to influence with the built environment—and with primary prevention work in general—we're not going to see those changes for a long time. And whenever you are trying to address chronic disease, many times it could be years before you see a change; many times it could be a generation before you really see a change in population level health outcomes.

And so, what we do is look to the research. And we look to the research to find out what the research says about the effectiveness of different types of infrastructure projects. And then, we try to use that to promote different types of projects that we can fund, and we evaluate based on things that we can see in the short term.

We focus on the access to physical activity infrastructure. We focus on the use. We focus on changes in perception and attitudes and behavior change. So, we try to look at the ways that people are interacting with their environment: are they thinking differently about their health as a result of being in a more active environment? Are we seeing more people using infrastructure as we improve it and provide it? Are we ensuring that we are promoting better access in communities?

If we have a community that doesn't have a place where the residents can go and walk, we need to provide that for them. And so, when we see that need, and then we can, in turn, provide a greenway or a walking track or a walking trail, we can then see that we've increased access. We've increased that opportunity for people to engage in a healthier life.

JOHNSON:
Are you seeing those short-term gains from the projects that have opened?

VICK:
We have asked each community to evaluate based on their own goals and needs. And so, we've evaluated the use of projects, we've evaluated attitudes, and we've also tried to make sure that we're collecting qualitative data as well because this is something that's new for a lot of communities, and certainly for a lot of the health departments in those communities. And so, we want to make sure that, we're understanding the context and that we're telling the story of what's happening.

Sometimes when you just collect numbers, you miss the context and you miss the story behind it. And so, we're trying to encourage people when they evaluate these projects to think about the qualitative pieces as well.

Sometimes they are unanticipated outcomes that are—they are incredibly important for this kind of work. We've noticed that there are a number of partnerships and collaborations that have resulted even for the small $10,000 grants in these communities.

There are examples where a local chamber of commerce or the city will donate a few thousand dollars, or the local fire department or a local builder will donate time to help install a playground. We're seeing communities come together around these projects. And those are the types of things—those partnerships, that collaboration, that community buy-in—that you might not get from just measuring the number of people using a space.

So, we try to collect both, and we try to encourage communities to think about how they can tell the story of these projects and how they've made a difference.

JOHNSON:
Anytime you're forging a new approach, that's going to be a little bit risky. What do you say to the public health professional listening to this interview about that risk and why it's worth taking?

VICK:
Well, I think we always have to be taking risks. There are many things that public health does very, very well; but I think that if we're really going to address those health conditions that are contributing to our leading causes of death—heart disease, cancer, stroke, diabetes—we're really going to have to think differently about how we're addressing those problems. And anytime you're doing something innovative, it's always a risk.

And I think what we're trying to do at the department is to think about what the research and the evidence say, and then take that and figure out a way for us to operationalize it and to bring that to communities.

I think by having these built environment grant programs, and by having these resources available, and by having regional coordinators who can help coordinate between the health and built environment worlds, I think we're showing communities that this is a priority. That this is something that impacts your health, and that this is something that we can do something about, and that we've made it a priority and we're putting money and staff behind it so that we can try to address it.

JOHNSON:
For more information about the CDC's Active People Healthy Nation campaign and Tennessee's Built Environment program, visit the show notes for this episode. You can find the links there.

Thanks for listening to Public Health Review.

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And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.