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Committee on Evaluating Progress of Obesity Prevention Effort; Food and Nutrition Board; Institute of Medicine; Green LW, Sim L, Breiner H, editors. Evaluating Obesity Prevention Efforts: A Plan for Measuring Progress. Washington (DC): National Academies Press (US); 2013 Dec 11.
Committee on Evaluating Progress of Obesity Prevention Effort; Food and Nutrition Board; Institute of Medicine; Green LW, Sim L, Breiner H, editors.
Washington (DC): National Academies Press (US); 2013 Dec 11.Why: Why develop a National Obesity Evaluation Plan? A National Obesity Evaluation Plan is essential for documenting progress, informing future direction on policy and environmental change at the national level, and providing support to state and community assessments, monitoring, surveillance, and summative evaluations.
What: What is a National Obesity Evaluation Plan? A National Obesity Evaluation Plan is a framework for evaluating progress in achieving the strategies recommended in the Accelerating Progress in Obesity Prevention report (IOM, 2012a) at a national level and serves as a model, template, or framework for state and regional evaluations. Much of the National Obesity Evaluation Plan, as distinguished from the evaluations of progress on more local efforts, centers on components and activities related to the development and maintenance of the infrastructure for continuous, nationwide monitoring and surveillance that regional, state, and community evaluations can use in their status assessments and progress evaluations.
How: How should the National Obesity Evaluation Plan be implemented? The National Obesity Evaluation Plan includes eight core activities: (1) establish key leadership, infrastructure, priorities, and timeline for implementation of the plan; (2) identify current federal monitoring, surveillance, and summative evaluation efforts; (3) harmonize and expand current federal monitoring, surveillance, and summative evaluation data collection; (4) develop new data collection instruments and systems to address gaps; (5) increase national and state capacity for monitoring, surveillance, and summative evaluation; (6) provide timely and relevant feedback from federal data; (7) ensure that federally funded programs include recommended indicators and common measures; and (8) encourage development and testing of new methodologies.
The Institute of Medicine's (IOM's) report Accelerating Progress in Obesity Prevention (APOP) (IOM, 2012a) presents a new way to frame obesity prevention by targeting policies, systems, and environments, rather than focusing on individual change, as many previous recommendations have done. The evaluation of recommendations and strategies in the APOP report requires a similar frame of reference, because prior evaluation efforts in the United States have focused predominantly on outcomes from individual-level interventions and largely ignored or only superficially included monitoring of obesity prevention policies and environmental changes or surveillance of the effects of them. Thus, commitment to the APOP plan of action requires a concomitant commitment to an expanded view of evaluation that includes outputs, outcomes, and impacts at the environmental, systems, programmatic, and policy levels (see Chapter 3, Figure 3-1). As explained in Chapter 1, national evaluation needs to include (1) monitoring of obesity prevention policies, environmental changes, and other interventions; (2) surveillance of the changes in obesity and obesity-related behaviors, determinants, and consequences; and (3) summative evaluation of the effects of interventions on the incidence and prevalence of obesity and obesity-related behaviors, determinants, and consequences. In this chapter, the Committee sometimes uses the term evaluation to refer to all three of these functions. The inconsistent and varied use of these three terms in the various sectors, agencies, disciplines, and professions involved in obesity prevention necessitates that the Committee's usage in this report will sometimes not match the way the term is used elsewhere. In addition, the use of consistent definitions in this report complements the use of evaluation as a term in biological and psychological research that lends itself more to individual-level studies and highly controlled experiments on the efficacy of interventions.
Many initiatives have targeted obesity prevention, but monitoring, surveillance, and summative evaluation plans within and across sectors and levels at the national and community levels have not yet been harmonized. Without the coordinated development of evaluation, uneven and stalled progress will go unnoticed and opportunities to correct efforts or build on successes will be missed. Although the United States previously developed a nutrition monitoring plan (Briefel, 2006; Briefel and McDowell, 2012) and a surveillance plan for Healthy People 2020 exists (Green and Fielding, 2011), the nation does not yet have an evaluation plan for obesity prevention as recommended in the APOP report (IOM, 2012a). This chapter describes recommendations for a U.S. National Obesity Evaluation Plan that can be used as a resource and model for state and regional evaluations. This chapter includes summaries of current international and national evaluation plans; an outline of a National Obesity Evaluation Plan to evaluate strategies identified in the APOP report; recommendations to adapt this plan at the state and regional levels; and considerations for how community and local level data, which will be discussed in Chapters 7 and 8, can be incorporated to enhance and support the National Obesity Evaluation Plan. In addition, because the Committee was tasked to identify measurement ideas for The Weight of the Nation (TWOTN) campaign, 1 this chapter discusses opportunities and challenges for evaluating this campaign within the National Obesity Evaluation Plan.
Chapters 1 and 2 focus primarily on “why” evaluation should be conducted. Chapters 3, 4, and 5 tackle “what” needs to be done and for “whom.” This chapter addresses the “how” of evaluation at the national level by proposing a concrete National Obesity Evaluation Plan, as well as recommendations for its implementation across multiple sectors (see Chapter 1), framed in a systems-level approach (see Chapter 9) that addresses health equity (see Chapter 5 and see Box 6-1).
Addressing Health Inequalities as Part of a Systems Approach in the National Obesity Evaluation Plan. As documented in Chapter 5, obesity-related disparities exist across various racial and ethnic groups and socially disadvantaged populations. Patterns (more. )
The Committee designed the evaluation framework offered in Chapter 3 (see Figure 3-1) to provide a logic model, including inputs, activities, outputs, outcomes, and impacts that can be easily applied to evaluation plans assuring timely and meaningful collection and analysis of data to inform and improve obesity prevention efforts at national, state, and community levels (Committee vision, Chapter 1). Aligning the National Obesity Evaluation Plan, as well as state- and community-level plans, with the evaluation framework provides context for the rationale and measurement components underlying the Committee's recommendations (see Chapter 10).
The National Obesity Evaluation Plan is outlined in Box 6-2. The plan was conceptualized to include an overarching purpose that is directly related to the strategies from the APOP report (IOM, 2012a) and the evaluation framework; a list of broad objectives that detail the steps that must be followed; and a list of more specific activities that result from operationalizing the objectives. The Committee understands that the activities, in particular, are ambitious and will likely be implemented over several years; however, to adequately determine the effectiveness of the APOP strategies and current efforts in obesity prevention, significant and bold changes in the current U.S. system for evaluation of progress in obesity prevention must be put into place.
Core Components and Activities of the National Plan for Evaluating Progress in Obesity Prevention. Purpose: To evaluate progress at the national level in implementing strategies from the IOM Accelerating Progress in Obesity Prevention (APOP) report (IOM, (more. )
For a national evaluation plan, differing population needs demand inputs of varied data collection. Context is also varied, spanning urban to rural geographies and affluent to poorer communities, so a national evaluation plan must be broad, adaptable, and culturally sensitive to cover various environments, languages, contexts, and populations.
Inputs also include objectives and goals that serve as evaluation benchmarks; they often link to national health goals, such as Healthy People 2020 (HHS, 2010b), and include specific populations (Green and Fielding, 2011). State objectives tend to be patterned after national obesity, diet, and physical activity objectives; many have been developed or adapted from the Healthy People 2020 template with Centers for Disease Control and Prevention (CDC) funding and guidance (CDC, 2012b).
Development of an evaluation plan aligned with a core set of national-level indicators is one of the primary activities outlined in the evaluation framework. State-specific indicators can provide further context and focus on individual issues that are likely to arise in localized areas. Infrastructure development is necessary as well, and it can range from the broader and more complicated infrastructure at the national level to smaller and more limited infrastructures at the state level. Available funding, workforce capacity, political will, and the perceived need for obesity prevention can affect infrastructure for collecting, analyzing, and reporting data.
The recommendations of the National Obesity Evaluation Plan outlined in this chapter represent one of the major outputs of the evaluation framework. The plan organizes designated indicators from Chapter 4, with comparisons and benchmarks for impact variables, using appropriate methodology and feedback opportunities to assess progress in obesity prevention. The recommendations and guidance for the evaluation can inform adaptation and implementation of the plan.
With implementation of the plan, several outcomes can be realized. Capacity and infrastructure for evaluation at both national and state levels will improve, leading to increased numbers and complexity of monitoring, surveillance, and evaluation activities. As well, data gleaned from these efforts can be disseminated back to stakeholders and consumers for use in informing decisions about resource allocation and intervention efforts.
Implementation of the plan will provide data from various sectors to document progress in obesity prevention. Although a variety of impacts are important, for obesity prevention the impacts of the plan reflect a multi-level and multi-sector focus that targets various interventions through a lens of health equity and includes changes in both environments and behaviors, mirroring the guidelines provided in the APOP report (IOM, 2012a).
Obesity is a worldwide problem, and, as such, world and regional organizations, as well as other countries, have proposed monitoring, surveillance, and evaluation plans for obesity prevention and control. To develop the National Obesity Evaluation Plan for the United States, the Committee examined international efforts as models to determine which components were applicable to the United States and consistent with APOP strategies (IOM, 2012a). Of particular interest were indicators or methodologies that could later be used across countries to facilitate cross-country comparisons. Comparing data from different countries can highlight innovative policy or programmatic efforts and outcomes and contribute to the body of evidence regarding effective obesity prevention strategies. A brief review of prominent international obesity plans follows.
The World Health Organization (WHO), International Agency for Research on Cancer, the European Commission, and the Ensemble Prévenons l'Obésité Des Enfants (or EPODE, Together Let's Prevent Childhood Obesity) European Network have produced plans for monitoring, surveillance, and evaluation of obesity prevention and control (Riboli et al., 2002; WHO, 2008). Single countries—Australia, the United Kingdom, and others—have documented obesity prevention evaluation plans (Australian Government Department of Health and Aging, 2010; WHO, 2007). In these countries, evaluation plans have built on existing national nutrition monitoring/surveillance systems and data infrastructures, many of which are more thoroughly and universally linked across record systems in those countries than in the United States because of the national health systems in those countries. Many of these plans include goals consistent with several APOP strategies, making them useful models for informing the U.S. National Obesity Evaluation Plan and enabling comparisons of progress with other countries and regions of the world.
The WHO has a framework that can be adapted by countries to evaluate the components of the WHO Global Strategy on Diet, Physical Activity and Health (DPAS) (WHO, 2008). DPAS, proposed in 2004, focuses on the worldwide increases in noncommunicable diseases as a result of poor dietary intake and activity levels (WHO, 2004). DPAS includes a strong emphasis on the role of government in providing leadership in these efforts. It calls for development of national dietary and physical activity guidelines and policies, coordination of agricultural policies, educational and health literacy efforts, multi-sectorial policies for physical activity, school-based policies to promote healthful diet and activity, and prevention efforts through health care or health services (WHO, 2004). The related WHO evaluation strategy (WHO, 2008) also calls for a monitoring, surveillance, and evaluation plan. The WHO European Database on Nutrition, Obesity, and Physical Activity (WHO, 2011) contains information on national and subnational surveillance data, policies, and actions to implement policies.
The WHO evaluation plan proposes that countries set up a process to ensure that monitoring, surveillance, and evaluation activities are included in all intervention plans, by identifying existing relevant activities and suitable partners, selecting appropriate indicators, and carrying out the monitoring, surveillance, and evaluation activities periodically in a consistent manner (WHO, 2008). The WHO recommends the development and tailoring of process, output, and outcome indicators by each country with consideration of national characteristics or culture, policy, settings, and available scientific evidence. The agency encourages evaluations of programs and initiatives that draw on existing monitoring and surveillance activities in each country (WHO, 2008). Key outcome indicators are grouped by periodicity/time scale, with short-, intermediate-, and long-term indicators. Indicators range from awareness of dietary and physical activity goals in the short term to physiologic factors, and dietary and physical activity behaviors in the intermediate term. Long-term outcomes, referred to as “impacts” in Figure 3-1, relate to overweight and obesity goals, as well as morbidity and mortality. The intent is that countries are encouraged to use these comprehensive strategic pillars to develop national evaluation plans with robust monitoring, surveillance, and evaluation components. Appendix F (F-1">Table F-1) presents other examples of international evaluation plans and activities.
The current U.S. national surveillance systems for obesity and related risk factors have many advantages, including a historical record that provides tracking of key impact measures, validated and reliable measures, biologic measures, and sample sizes that provide population-level estimates for various subgroups, focused on individual-level data. In addition, Healthy People 2020 (HHS, 2010b) and Physical Activity Guidelines for Americans (HHS, 2010a) provide a framework of objectives and key indicators that inform national evaluation efforts and influence the items available in the National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS), Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Surveillance System (YRBSS), and other surveillance systems. Although the majority of data are available at the national level, sampling of selected regions by the BRFSS—Selected Metropolitan/Micropolitan Area Risk Trends (SMART) allows the use and comparison of national, state, and some city/county variables at representative levels for selected communities. Several of these factors are also consistent with the WHO framework to monitor and evaluate obesity prevention efforts (WHO, 2004). Finally, the expanded use of technology has allowed for rapid collection and analysis of some types of data to provide tools that can potentially be replicated at other levels and could provide data on incidence of obesity and related outcome indicators, in addition to the usual prevalence estimates.
The current national monitoring/surveillance system can track obesity prevention efforts and their effects, and it has several strengths as detailed above; however, gaps in the current system exist. These gaps include a lack of data to enable monitoring of key policy, systems, and environmental strategies that are highlighted in the APOP report (IOM, 2012a); a decentralized leadership with limited authority, responsibility, or support and coordination at the national level; 2 a paucity of physical activity and environmental indicators to enable surveillance of nutrition and obesity measures; a lack of data for certain populations or child developmental levels; gaps by time period or region; a lack of measurement of the incidence of obesity; a lack of resources and infrastructure for surveillance and timely reporting of results; and a lack of data for use at the community level.
Lack of monitoring of policy and environmental data. To date, the majority of monitoring and program summative evaluation data have used individual-level measures, because those have been the focus of most intervention efforts, programs, and government recommendations in the past (Green et al., 1974; Marketing Economics Division, 1972; Wang and Ephross, 1970; Wang et al., 1972). The APOP report (IOM, 2012a), however, frames obesity prevention efforts ecologically in terms of policy, systems-level, and environmental approaches, which require new evaluation approaches and measures. In particular, comprehensive monitoring, surveillance, and summative evaluation systems are needed for all settings, including early child care, schools, worksites, and health care. These systems can be difficult to implement and maintain, mostly because of the lack of an overall national organizational structure and incentives for obesity prevention in these settings. Finally, databases and methods to track exposure to media messages about diet or physical activity are needed to monitor progress in improving the messaging environment (APOP Goal Area 3, IOM, 2012a).
Lack of data for certain populations. Many existing national monitoring and surveillance plans are designed to oversample various subgroups of the population, such as low-income persons and minorities, but data remain limited for some segments of the population, such as the homeless, and certain racial/ ethnic groups, such as Native Americans, Latino/Hispanic subgroups, and Asian Pacific Islander populations (Koh et al., 2012; Wang and Beydoun, 2007). Special subnational studies offer the most economical way to cover these and other minority groups as part of a National Obesity Evaluation Plan, as outlined in Chapter 5.
In addition to expanded coverage of population subgroups, improved geographic coverage is needed to provide obesity data at state and community levels. The CDC surveillance systems (e.g., BRFSS, YRBSS) provide data for participating states that are complementary to national data, but there is increasing interest in collecting state data to address local health and welfare concerns, as well as to collect data on state-level policies and environments and enhanced sample sizes in selected local populations. For example, the California Health Interview Survey 3 provides data on specific racial/ethnic populations such as Latinos living within California. Another example is the Lower Mississippi Delta Nutrition Intervention Research Initiative funded by U.S. Department of Agriculture (USDA), which uses evaluation and community participatory methods to assess diet and chronic disease in a three-state region (Ndirangu et al., 2010).
Overlap of existing data collection efforts. The current U.S. monitoring/surveillance efforts include some overlap of data collected by different monitoring/surveillance systems. For example, similar school policy and environmental measures are collected in School Health Policies and Practices Study (SHPPS), School Nutrition Dietary Assessment Survey (SNDA), and Bridging the Gap assessments. By coordinating efforts and having a designated task force/entity to oversee this process, duplication of activities could be minimized and resources could be better leveraged.
Gaps in monitoring and surveillance by periodicity, setting, or region. Although some systems for collection of data about policies and environments exist, such as the SHPPS survey, the data are not collected at regular enough intervals to inform and provide adequate feedback on actions to prevent obesity or to improve the implementation of existing policies and interventions. In addition, with longer time periods between data collection, it is difficult to maintain consistent funding and infrastructure over time, resulting in duplication of effort and loss of institutional knowledge about the surveys. For example, SHPPS data are collected every 6 years, which is helpful for long-term trends but does not provide real-time data for decision makers. The APOP report (IOM, 2012a) recommended that SHPPS data collection be adjusted to once every 2 years. Modifying that to include different settings such as worksite, child care centers and schools, a 3-year measurement period could be instituted. Data could be collected on a rolling basis with alternate surveys in different environments in different years so that, for example, schools could be surveyed one year, child care settings could be surveyed the following year, and worksites surveyed the third year.
Lack of infrastructure at regional and state levels. The current national monitoring and surveillance systems have evolved to use sophisticated and systematic measures and technology infrastructure to support data collection, cleaning, analysis, and reporting, as well as specialized knowledge and technical expertise. Often, the infrastructure or capacity for this type of data collection is lacking or not as well developed at the regional or state levels; this capacity is also lacking at local health departments as addressed in Chapters 7 and 8. In addition, although the knowledge and expertise for sampling methods and measurement theory may exist in the state, this type of expertise might not be found at the state health department or in state government. To increase workforce capacity for monitoring, surveillance, and summative evaluation, it is essential to incorporate elements of public health and surveillance into health professionals' education (Drehobl et al., 2012).
Lack of standard indicators and measures. Although relatively standard methods of collecting individual-level data are available and frequently used (e.g., body mass index), there is less standardization of policy, systems, and environmental indicators and measures. Recently, efforts to develop measures for policies and environments for food and physical activity have been spearheaded primarily by the Robert Wood Johnson Foundation through the Bridging the Gap, Active Living Research, and Healthy Eating Research programs (Ottoson et al., 2009; RWJF, 2013a,b; University of Illinois at Chicago, 2013a). Many of these measures have been evaluated for psychometric properties such as validity and reliability and are now being used consistently in research studies. Along with the physical and policy environment, the behavioral environment should also be assessed, including social norms for diet, physical activity, and obesity.
The National Obesity Evaluation Plan for assessing progress in obesity prevention builds on the current strengths and infrastructure of the existing monitoring and surveillance systems in the United States, including Healthy People 2020 (HHS, 2010b), but it proposes the incorporation of new infrastructure (i.e., surveys and sources of data) to measure policy, systems, and environmental indicators (see Box 6-2), as well as integration with international efforts. The plan includes many of the proposed methods and indicators outlined in the WHO Global Strategy on Diet, Physical Activity and Health: A Framework to Monitor and Evaluate Implementation (WHO, 2008) and thus will be consistent with similar evaluation efforts internationally. Insofar as APOP strategies (IOM, 2012a) focus largely on policy, systems, and environmental approaches, while existing assessment, monitoring, surveillance, and summative evaluation efforts primarily focus on individual-level outcomes, the plan needs to align the newer intervention approaches with appropriate indicators.
Components of the plan are tied to proposed activities, including identification of overall leadership, infrastructure, resources, and timeline for the plan; identification of current federal efforts and data gaps; proposals for additional and new measures, infrastructure, and data collection systems to address these gaps; mechanisms for feedback to data users; and adaptations of the plan to state and regional applications (see summary Table 6-1). Plan activities need to prioritize and leverage existing resources to maximize efficiency of data collection, as well as to avoid duplication of efforts. Several of the proposed activities could be implemented relatively easily and with little cost as, for example, new questionnaire items added to the BRFSS or the YRBSS. Other recommendations, such as decreasing the time period for SHPPS from 6 years to 3 years are relatively expensive, and therefore must be balanced with other priorities. Other considerations when prioritizing recommendations include
Summary of Potential Activities and Examples of Implementation Steps for Addressing Components of the National Obesity Evaluation Plan.
Which sectors to target with priority? Are the appropriate stakeholders and potential users involved in setting these priorities and providing feedback (see Chapter 2)?
What is the appropriate time frame for each measurement? Does this fit within the time frame needed to evaluate obesity prevention efforts?
How precise do the measures for the indicator need to be? Can a survey tool be used, or is a more objective or precise measure required?
Which populations need to be measured? Do survey planners need to oversample certain racial and ethnic groups, such as pregnant women or Native American populations?
To be relevant, as well as to address the current status of APOP strategies (IOM, 2012a), evaluation activities for the National Obesity Evaluation Plan should follow the steps outlined in Chapter 8 (see Figure 8-1 and Table 8-1), using existing monitoring and surveillance systems as data sources. Briefly, this process includes setting appropriate intervention goals and time frame based on the specific APOP strategy and intervention being measured. As well, a logic model or theoretical framework detailing the inputs, outputs, and outcomes/impacts (short-term, long-term, and ultimate) should be developed. When possible, these evaluation activities should be planned to coincide with existing monitoring/surveillance activities and dates. Alternately, a separate and more intensive evaluation could be conducted during an “off year” for a national survey to provide additional data, additional questionnaire items could be added to an existing surveillance system, or priority populations (e.g., Supplemental Nutrition Assistance Program [SNAP] recipients) could be oversampled.
To illustrate, a few concrete scenarios on how the National Obesity Evaluation Plan might initially take shape are provided in Table 6-2. A separate example was developed for each level of the social ecological model as proposed by the IOM (2007b) and in the APOP report (IOM, 2012a) (see Figure 3-2).
Examples of Potential Changes Needed to Implement the National Obesity Evaluation Plan for Monitoring and Surveillance of Progress in Obesity Prevention.
The implementation of the National Obesity Evaluation Plan calls for strong commitment and coordination at the federal level, with establishment of an obesity task force or other federal entity to oversee plan activities. Leadership activities include providing an effective national leadership structure for these activities; ensuring adequate benchmarks and guidelines for the plan; setting processes for prioritization, funding, accountability, and adaptation; and creating a timeline and management structure for activities, as proposed in the WHO framework (WHO, 2008).
Convening a federal obesity evaluation task force/entity to oversee the National Obesity Evaluation Plan would be an appropriate first step to guide its development. This task force could be part of an existing committee, such as the Department of Health and Human Services (HHS) Healthy Weight Task Force or the National Prevention Council or could be a newly organized committee that would coordinate with appropriate partners, such as the HHS Healthy Weight Task Force; the National Prevention Council 4 and multi-agency representation; National Collaborative on Childhood Obesity Research (NCCOR); the Interagency Committee on Human Nutrition Research; the President's Council on Fitness, Sports, and Nutrition; and other appropriate national committees. Representatives on the task force or entity would include federal agencies involved in coordinating existing assessments, such as the CDC (NHANES, NHIS, BRFSS, YRBSS, Pregnancy Risk Assesssment Monitoring System [PRAMS], SHPPS), USDA, NCCOR (CDC, National Institutes of Health [NIH]/National Cancer Institute [NCI], Robert Wood Johnson Foundation [RWJF], and USDA), and Health Resources and Services Administration's community health centers, as well as other sectors that are involved in dietary and physical activity policies, such as the Departments of Education and Transportation. In addition, representatives from other groups that are conducting extensive monitoring, surveillance, or summative evaluations, and representatives from major stakeholder groups, such as child care settings, schools, worksites, local and state government, public health departments, and communities ideally would be included, either as committee members, or as part of an Advisory Committee. Examples of organizations that might be represented include the Nielsen Corporation and the National Restaurant Association, as well as advisors from the WHO or other countries where similar plans have been implemented. Creation of a task force to oversee the plan is a model followed not only in the WHO guidelines, but also in other national surveillance program plans. For example, in 2003, the National Forum for Heart Disease and Stroke Prevention, a collaborative of more than 80 organizations committed to the elimination of cardiovascular disease, created A Public Health Action Plan to Prevent Heart Disease and Stroke (CDC, 2003; National Forum for Heart Disease and Stroke Prevention, 2008). Central to its action plan is the creation of a comprehensive national and state cardiovascular disease surveillance program to provide accurate and timely information to accelerate progress in cardiovascular disease prevention. The recommended initial step in creating the cardiovascular disease surveillance system in the Public Health Action Plan to Prevent Heart Disease and Stroke report is similar to what is proposed in the current report: establish leadership through a national coordination unit (National Forum for Heart Disease and Stroke Prevention, 2008).
To provide benchmarks and guidelines for indicators for the National Obesity Evaluation Plan, it is necessary to have current national goals and objectives. The United States has robust national goals for health (Healthy People 2020, HHS, 2010b), diet (Dietary Guidelines for Americans, HHS, 2010a), and physical activity (Physical Activity Guidelines for Americans, HHS, 2008). By mandate, Healthy People and the Dietary Guidelines are updated on a periodic basis; unfortunately, the Physical Activity Guidelines do not have the same mandate, and thus, it is recommended that regular updates to the Physical Activity Guidelines for Americans mirror the periodicity of the Dietary Guidelines (e.g., every 5 years). In addition to the national recommendations listed, the APOP strategies for prevention of obesity (IOM, 2012a) guide the indicators and measurement systems proposed in the National Obesity Evaluation Plan.
An initial assignment for the obesity evaluation task force would be to provide a process for prioritization of plan recommendations, accountability, and adaptability or revision, including a review of the existing national obesity reports and objectives. In light of federal budget realities, recommendations will need to be prioritized, with rapid implementation of relatively easy and low-cost provisions, followed by long-term planning for more difficult or less developed indicators and systems. Accountability is crucial to measuring progress and will entail an annual report to whatever agency is leading this effort on prioritization of recommendations, plans, and progress. A timeline for implementation of the National Obesity Evaluation Plan would provide for short-term objectives achievable within 1–3 years, intermediate-term objectives achievable within 3–5 years, and long-term objectives for 5 years or more (see Box 6-2).
The APOP efforts that would be evaluated in the National Obesity Evaluation Plan would also need to be prioritized, based on current policy initiatives, media programs, national or multi-state programs under way, or potential significant environmental changes such as voluntary industry-initiated changes in food marketing or formulation. Ideally, the federal obesity evaluation task force would oversee this activity and would be responsible for soliciting stakeholder input to help to guide the process. Use of the evaluation framework presented in Chapter 3 would provide a roadmap for identifying inputs for the specific intervention or APOP strategy, the outputs as a result of the change or the initiative, and the outcomes/impacts. To determine the effects of national obesity prevention interventions, data from U.S. monitoring/surveillance systems could be used to determine changes in specific outcomes such as BMI over time (pre/post or time series), or, alternately, U.S. data, intervention efforts, and trends could be compared to similar countries. Cross-country comparisons have been previously used to document changes in secular national trends in lifestyle behaviors such as nutrition and cardiovascular disease outcomes in the Seven Countries Study (Menotti et al., 1993).
Evaluating nationally based or federal interventions can be challenging. Because these programs or policies are wide-reaching by design, it is difficult to use a more rigorous controlled trial or study design; these interventions are often implemented together with other initiatives, so it is difficult to determine the relative contributions of each component to measured outcomes; and existing surveillance systems may not adequately assess program outcomes or impacts. When federal initiatives are rolled out over a specified time period, it is often possible to compare outcomes in states that are early adopters to outcomes in states that are more likely to be laggards. Collection of process evaluation data, such as program reach, fidelity, and dose, can also provide useful evidence for effectiveness of obesity prevention interventions in state-level comparisons. Because of these limitations, at the national level it is advantageous to use monitoring and surveillance data to observe trends over time, for both implementation of interventions and APOP strategies, as well as for intended outcomes and impacts.
In the National Obesity Evaluation Plan, many of the proposed monitoring and surveillance activities are consistent with current U.S. efforts, as well as other national and international recommendations and surveillance/data systems, such as the WHO evaluation framework (WHO, 2008). Evaluation activities at the federal level often consist of reports examining results of existing surveillance systems, or specifically designated surveys, such as the SNDA. The SNDA provides monitoring of the nutritional content of school meals and the school nutrition environment and of student intake over time in response to changing school meal guidelines and rules (Briefel et al., 2009; Fox et al., 2009).
Additionally, obesity prevention interventions that are implemented nationally cannot necessarily be evaluated using a rigorous study design or controlled trial. For example, at an IOM workshop, Robert C. Hornik described five approaches often taken when a randomized controlled trial is not possible for evaluating mass media campaigns: long-term cohort studies, geographic cross-community comparisons, interrupted time series studies, associational time series studies, and other study designs (e.g., quasi-experimental) (IOM, 2012b). Hornik (IOM, 2012b) and Sanson-Fisher et al. (2007) discuss the strengths and weakness of each of these approaches. Hawkins et al. (2007) and Mercer et al. (2007) weigh in on the trade-offs among them in public health campaigns (see Table 6-3). Chapter 8 provides further resources and guidance on the diverse study designs and methods for tracking interventions.
Five Approaches to Evaluating Large-Scale Communication Programs.
To conduct these types of studies nationally, it is often advantageous or feasible to draw on data derived from monitoring and surveillance systems, rather than to mount ad hoc original surveys. As with cross-state comparison, cross-country comparisons can be conducted using quasi-experimental designs, but again, these comparisons often rely on surveillance systems that use consistent indicators, measures, and methodologies across countries and over time. Therefore, much of the focus of the National Obesity Evaluation Plan is on existing and proposed surveillance activities, from which data can be derived for evaluation efforts, at the national level, and potentially at the state and local levels.
The Committee's assessment of current monitoring and surveillance activities in the United States found that several potential components of a national evaluation plan for obesity prevention exist, but there are challenges and barriers to improving national gaps in indicators, methodology, and reach. For example, the national nutrition surveillance systems are designed to meet the specific data needs of multiple stakeholders. There are competing priorities for collecting information to meet data needs, and improvements in design, coordination, and data collection recommended by expert groups (Briefel and McDowell, 2012; NRC, 2005; Woteki et al., 2002) have been hampered by insufficient funding and a centralized coordinating body for obesity. To fully understand the current challenges and barriers to fully implementing a National Obesity Evaluation Plan, it is useful to understand the pertinent history and structure underlying the current systems for data collection to draw on “lessons learned” to justify the proposed plan objectives and activities. In addition, examination of past and current evaluation efforts are needed to effectively use existing resources and data sets, to minimize duplication and unnecessary response burden on the practitioners and public asked to provide data, and to anticipate potential resistance to changes in survey or other surveillance system items or wording that might make their results less useful in comparison with past data. Below is a brief legislative history of U.S. surveillance efforts related to nutrition, physical activity, and obesity and how these efforts have evolved to meet increasing needs for other types of data.
Nutrition surveillance. National nutrition surveillance activities began in the late 1890s with the development of food composition databases. The first national dietary surveys were conducted in the 1930s. Body mass or corpulence status based on measured height and weight has been measured since the first National Health Examination Survey in 1960–1962, the predecessor of today's NHANES. Since then, more than 35 national surveys, surveillance systems, and databases have been developed to meet the varied and changing information needs of federal agencies, researchers, and data users (Briefel, 2006; Briefel and McDowell, 2012; Life Sciences Research Office, 1995).
The U.S. nutrition surveillance system was formally established with passage of the Food and Agriculture Act of 1977 (Public Law 95–113, 95th Cong., September 29, 1977), leading to federal efforts to coordinate nutrition surveys and other national health surveys in the late 1970s and 1980s (Green et al., 1983) and the passage of the National Nutrition Monitoring and Related Research Act of 1990 (Public Law 101–445, October 22, 1990). A Ten-Year Comprehensive Plan guided federal actions for nutrition surveillance from 1992 to 2002 (HHS and USDA, 1993) and identified three national objectives critical to the success of a coordinated, comprehensive nutrition surveillance program:
a comprehensive program through continuous and coordinated data collection;
comparability and quality of data across the program; and
improvement of the research base for nutrition surveillance.
The Ten-Year Plan provided the framework for (1) the integration of the two national dietary surveys, HHS's NHANES, and the USDA's Continuing Survey of Food Intakes by Individuals (Murphy, 2003; Woteki, 2003); (2) the expansion of specialized databases for food composition and food access; and (3) quality-control mechanisms and studies to evaluate nutrition assistance programs and nutrition standards through monitoring of interventions. Monitoring data from these activities has often been used to assess ongoing changes in school meals as a result of new legislation (e.g., reauthorization of child nutrition programs). Despite support from the scientific community (Woteki et al., 2002), the nutrition monitoring/surveillance legislation was not renewed in 2002. Surveillance activities are continuing in the United States, but without the formal, coordinated guidance of an interagency board or legislative mandate. This lack of a designated task force to coordinate monitoring and surveillance data to evaluate obesity progress is a barrier to coordination of collecting data on new indicators, creating or expanding data systems, and reducing duplication of effort.
The current nutrition monitoring system and activities provide a foundation to build on for the national obesity evaluation plan. The most widely used and cited U.S. national survey for the surveillance of obesity and related behaviors is the NHANES, which includes objective measures of height and weight, diet, 5 and physical activity risk factors, and other chronic conditions associated with obesity. NHANES data are collected at the individual level, which means that information to monitor environments and policies is not included systematically in the same data systems. Continuous since 1999, NHANES has an annual sample design that includes over-sampling of racial/ethnic groups, low-income white persons and, at times, pregnant women. NHANES provides nationally representative data and is not designed to provide state- or community-level estimates. However a representative sample of New York City adult residents participated in the New York City Health and Nutrition Examination Survey (NYC HANES) in 2004, and a second NYC HANES was scheduled for 2013 (NYC Department of Health and Mental Hygiene, 2013). Similarly in 2011, the Department of Public Health for the County of Los Angeles begun a pilot project to establish a local health profile description of adult obesity and related cardiovascular disease risk factors called the Los Angeles County Health and Examination Survey (Fielding, 2011). These efforts may serve as a model for other cities or communities that have the resources to replicate NHANES protocols to collect objective obesity and related health measures for surveillance or summative evaluation purposes.
The NHIS provides large sample sizes and information on self-reported height, weight, and comorbid conditions commonly associated with obesity. National and state nutrition surveys have provided surveillance data on topics such as knowledge, attitudes, and behavior about diet and nutrition; food shopping practices; weight loss practices; and breastfeeding practices. Data from these surveys have been used to evaluate the effects of national nutrition policies, programs, and practices on special populations, such as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or SNAP participants (see Table 4-2, Appendix Tables D-1 and F-2).
State surveillance systems have historically been an integral part of past national activities to track nutrition at the state level and more broadly at the national level if all or most states participate to assess progress in meeting obesity-relevant national health objectives. The BRFSS and the YRBSS provide self-reported weight and height and limited measures of diet and physical activity behaviors every 2 years. Both systems can provide data at multiple representative levels (national, state). Further details can be found later in this chapter's section on Surveillance Systems and in Appendix Table D-1. CDC has traditionally administered other data systems that could be used for obesity-related measures, such as the Pediatric Nutrition Surveillance System (PedNSS) and the Pregnancy Nutrition Surveillance System (PNSS). Both of these state-level surveillance systems began in the 1970s and 1980s to focus on young, low-income children and their mothers, because sample sizes for these high-risk groups in NHANES were fairly small. Despite the utility of these data to provide information on key populations of interest, both programs were discontinued in 2012, with the last data collected in 2011 (NCCOR, 2013). The decision to move data collection for selected indicators from these surveillance systems to WIC eliminates the technical assistance to states and local agencies to obtain data previously collected through PedNSS and PNSS; 6 federal budgets are not sufficient to do new and continuing data systems. 7
Physical activity surveillance. Although physical activity is a key determinant of obesity and chronic disease, surveillance of physical activity in the United States has not been as robust as for diet or obesity. For surveillance of physical activity among adults and adolescents, the NHIS and the YRBSS have been used to track Healthy People 2020 progress (Carlson et al., 2010; HHS, 2010b). Accelerometers, introduced to measure physical activity in the 2003–2004 NHANES, improved physical activity measurement, which had previously relied on self-report or parental reports for children. Efforts have also been made to develop measures of inactivity (e.g., the number of hours of screen time or time spent sleeping) and physical activity environments at child care centers, schools, and in communities (NCCOR, 2013).
The lack of adequate physical activity surveillance may be related to the only recent attention to and development of national physical activity guidelines. For example, the Dietary Guidelines for Americans have been mandated since 1977 (HHS, 2010a), but the Physical Activity Guidelines for Americans have existed only since 2008 (HHS, 2008). A National Physical Activity Plan—“a comprehensive set of policies, programs, and initiatives that aim to increase physical activity in all segments of the American population” was developed recently by a private-/public-sector collaborative (Coordinating Committee and Working Group for the Physical Activity Plan, 2010), but as of 2013 only one state had developed a plan that specifically addresses physical activity (Duke, 2009; Kohl et al., 2013). An initial evaluation of the National Physical Activity Plan has been funded by CDC and includes assessment of implementation reports from each of the identified sectors, case studies of several states implementing aspects of the plan, and a survey of members of the National Society of Physical Activity Practitioners in Public Health (Bornstein et al., 2013; Evenson et al., 2013a,b; Kohl et al., 2013).
The relative early field-building status of physical activity in health and the lack of benchmarks for surveillance and summative evaluation of physical activity, and of consensus on validated measures of environmental determinants, at the national, state, and community levels likely contribute to the paucity of surveillance data on physical activity (Ottoson et al., 2009). The relatively recent acknowledgement of physical inactivity as a separate health risk may be another contributing reason (Kohl et al., 2012; Lee et al., 2012).
National obesity-related policy monitoring, surveillance, and summative evaluation. Currently, the only national obesity-related public policy monitoring/surveillance systems focus on state laws and school district wellness policies and on food and beverage taxation (see Appendix Table D-1). The monitoring of policy implementation is useful for tracking progress and changes in codified public policies over time and across jurisdictions, for assessing their implementation, and for examining factors influencing policy adoption. Policy surveillance is useful for examining the reach and impact of public policies on changes in related outcomes or impacts at the national, state, community, and individual levels.
The NCI's Classification of Laws About School Students (CLASS) (NCI, 2013) and the Robert Wood Johnson Foundation–supported Bridging the Gap (BTG) program (University of Illinois at Chicago, 2013a) both include quantitative measures of the strength and comprehensiveness of codified state statutory (legislative) and administrative (regulatory) laws for each of the 50 states and the District of Columbia related to school-based nutrition and physical activity. The CLASS and BTG systems are complementary and assess similar topics, but the state laws are analyzed using different analytic coding schemes and different time points (December 31 of each year for CLASS and the beginning of each school year for BTG). BTG also conducts the largest, ongoing, nationwide evaluation of the congressionally mandated school district wellness policies (University of Illinois at Chicago, 2013b). BTG also compiles annual quantitative data on codified state safe routes to school-related laws, farm-to-school laws, and food and beverage taxation (Chriqui et al., 2012; National Association of State Boards of Education, 2013; University of Illinois at Chicago, 2013a).
In addition to the policy monitoring and surveillance systems, several organizations maintain bill-level tracking systems for monitoring the introduction, adoption, and/or repeal of individual-level bills and/or session laws across the 50 states and the District of Columbia: CDC's Chronic Disease State Policy Tracking System, the National Conference of State Legislatures, the School Nutrition Association, and the Rudd Center for Food Policy and Obesity (CDC, 2013c; National Conference of State Legislatures, 2013; Rudd Center for Food Policy and Obesity, 2013; School Nutrition Association, 2011). Although these systems do not provide quantitative data on the current status of state laws, they provide useful information for evaluating policy activity and related advocacy efforts.
In addition to previously described national and state surveys, other indicators drawn from current studies (see Appendix Table D-1) are proposed as part of the National Obesity Evaluation Plan based on the specific measures, target population, and level of the data desired (see Appendix Table F-2) for indicators. For example, evaluations of USDA nutrition assistance programs periodically provide information on the dietary intakes and on the nutrition and health behaviors of program participants, who are often low-income and/or disadvantaged populations (e.g., National Household Food Acquisition and Purchase Survey; Studies of Child and Adult Care Food Program; Studies of WIC Participants; see Appendix Table F-2). Some of these studies collect height and weight and obesity-related behaviors from participants at WIC clinics (NCCOR, 2012) or public schools. Data from the SNDA help to monitor progress in school nutrition policies. Data from the SNDA have been instrumental in addressing changes to competitive food policies and school meal regulations to increase dietary quality and reduce excess calories in light of childhood obesity (IOM, 2004, 2007a), and they have been used to assess the relationship between school nutrition policies and students' diet and weight status (Briefel et al., 2009; Fox et al., 2009).
Other school-level environmental data can be obtained from the SHPPS, which provides data on health-related policies and practices at the school level, some of which include diet and physical activity. These data are often used for state-by-state comparisons to measure progress in implementation of state policies across the United States (CDC, 2006). Unfortunately, SHPPS is administered only every 6 years, and similar surveys are not available in other settings, such as child care, worksites, and health care clinics, probably because of the heterogeneous structure of these settings and the lack of definitive “umbrella” agencies that collect data for these entities analogous to the National Center for Education Statistics (Institute of Education Services, 2013), which collects data related to schools, and USDA, which collects data on school meal programs. Although some states might provide information for these types of organizations, the lack of a central organizational structure at the federal level is a barrier to identification of individual units for a sampling frame, as well as to accountability for conduct of the surveys. SHPPS might provide a useful model for data collection in these other settings.
One recent effort to measure the messaging environment was outlined in a recent updated report by the Federal Trade Commission on food marketing to children and adolescents (FTC, 2012). These reports, though laborious and expensive, if done regularly would provide excellent monitoring of the nutritional profile of foods marketed to youth, marketing activities directed to youth, and other marketing initiatives undertaken by food manufacturers. For example, the Healthy Weight Commitment Foundation—a voluntary effort by retailers, food and beverage manufacturers, restaurants, sporting goods and insurance companies, trade associations, nongovernmental organizations, and professional sports organizations to promote ways to achieve a healthy weight—provides additional data opportunities for evaluation efforts (Healthy Weight Commitment Foundation, 2013). Several proprietary databases, including the National Consumer Panel (formerly known as A.C. Neilsen's Homescan), collect information on household food purchases based on consumers transmitting data on scanned purchases, including fresh foods, weekly through a telephone line. Other proprietary databases include scanner data, food prices, and household purchases, but they are limited in that they include only foods purchased at retail stores and not foods purchased at restaurants (NRC, 2005; see Appendix Table F-2). These kinds of data sources, if made publicly available, could provide excellent surveillance of consumer behavior.
As previously stated in Chapter 4, indicators for the National Obesity Evaluation Plan are based on existing surveys and surveillance systems, such as NHANES, NHIS, National Survey of Children's Health, BRFSS, YRBSS, and SHPPS (see Table 4-2). Table 6-4 outlines indicators for the National Obesity Evaluation Plan based on available data sources, and indicates, by color coding, which indicators are in place (green), which are relatively easy to adapt to existing systems 8 or are partially in place 9 (yellow), or which will require further development and/or implementation (red) at the national and state levels. In addition, Table 6-4 maps these indicators to those outlined in the WHO diet, physical activity, and health evaluation plan (WHO, 2008), as categorized by the APOP goal areas. Key overarching or systems-level indicators such as adult and child prevalence of obesity and incidence of obesity are also included. Based on the initial work done for this report, gaps in indicators collected from/on representative samples are especially evident for assessment of early childhood education settings, worksites, health care groups, policies, and food marketing.
Indicators Currently Available for Use at the National and State Levels, with Comparison to World Health Organization (WHO) Proposed Indicators.
The WHO report also identifies process-level indicators necessary for the infrastructure, coordination, and accountability of an integrated evaluation plan. The Committee recommends the addition of similar process-oriented indicators in the National Obesity Evaluation Plan and state plans, such as (1) establishment of a coordinating and oversight federal obesity evaluation task force; (2) establishment of benchmarks, guidelines, and/or any related legislation for diet and physical activity; (3) establishment of an advisory committee to the oversight obesity evaluation task force with stakeholder input; (4) designation of a training and technical assistance center; (5) coordination of the monitoring and evaluation system; and (6) development of a standardized system for data feedback to stakeholders.
Maximizing use of current monitoring/surveillance and summative evaluation efforts is important, because many of these systems are already in place, have existing resources, and answer to designated constituencies. To accomplish this, it is necessary to harmonize metrics across systems and coordinate and expand existing systems after priorities are identified. Coordination of efforts across current surveillance and evaluation structures can minimize duplication of effort, leverage resources, and maximize use of data, as well as prioritize data to address strategies addressed in the APOP report (IOM, 2012a). The coordination of these efforts would require planning and additional resources, but building on existing frameworks and field experience is practical and would involve leveraging of existing funds (see Recommendation 2 in Chapter 10).
Harmonization also includes enhanced data collection through standardization of current metrics and coordination of different data systems, which is a more intermediate step in the process. For example, electronic health records (EHRs) can be standardized to facilitate aggregation of data across different health care plans across the United States. Initiatives such as Integrating the Healthcare Enterprise 10 are examining ways to promote and coordinate established standards for sharing of electronic health information. Similar standardization and aggregation can occur with data from WIC and Head Start and the proposed revision of birth certificates. 11 Common tools and methods for measuring indicators can be specified through NCCOR and promoted for community- and grant-level work, building on the indicators proposed in Table 6-4.
The Committee found several areas to expand on existing monitoring/surveillance systems, such as SHPPS and NHANES, by increasing frequency of measurements, or by collecting data on specific populations or developmental age groups. These changes could be prioritized as first steps, but should be balanced with other priority issues. For example, NHANES data collection could be expanded to include populations at increased risk for development of obesity/overweight, such as pregnant women, to collect specific information on perinatal obesity-related correlates. Another important addition would be to provide expanded age groups for children and adolescents that more closely correspond with stages of development, so that intervention efforts can be tailored to more effectively address pubertal and cognitive changes, as well as school level (e.g., middle school versus high school). Currently, adolescents aged 12 through 19 are grouped together, despite large differences in factors such as developmental level, school setting, and mobility. Further, college-age youth are not separately examined although colleges were identified in APOP as a setting of interest.
The final areas of enhancement will require additional resources and may be considered more long-term goals. These include the development of new data survey tools and infrastructure to address gaps in settings such as early childhood education, worksites, and health care. Some of these systems can be patterned after existing data collection methods. However, others will need more careful thought and planning, new sampling methods and enhanced sample sizes for local evaluations, development of infrastructure to support data collection and analysis, and new partners. Infrastructure development can include distributed data systems, and data collection using tablets or cell phones, with the capability to aggregate into a nationally representative sample.
Because the APOP report emphasizes both the built and the social environment, public perceptions, norms, and other social environmental measures will need to be derived from or added to existing surveillance systems, such as NHANES. In addition, indicators for physical activity and inactivity need to be included or strengthened in many of the existing monitoring/surveillance systems. Benchmarks for physical activity measures also are needed, which require scheduled and regular updates to the Physical Activity Guidelines for Americans (HHS, 2008).
A well-trained workforce is necessary for continued monitoring, surveillance, and summative evaluation activities (Drehobl et al., 2012). Unfortunately, although it is estimated that there is an impending lack of public health workers to meet national demands, an exact accounting of the workforce in training and what skills will be needed has not been done. The National Obesity Evaluation Plan calls for accelerated expansion and development of this workforce through increased training and technical assistance, as well as increased emphasis on courses in public health and practical experiences for health professionals (Drehobl et al., 2012). Funding evaluator positions in national, state, and regional agencies is also necessary, and this can be accomplished through creative means such as academic health department linkages, where university-public partnerships produce data both for the use of the health department and for peer-reviewed publications (see Chapters 2, 7, and 8 for further discussion of training and technical assistance for those at the community level).
Training and technical assistance for those who would implement and use data systems are crucial for quality control of measurements. They need to be conducted at all levels (national, state, local) to ensure data integrity and to facilitate standard methods and data. The National Obesity Evaluation Plan includes trainings on standardized measurement protocols for anthropometric and other measures. It also calls for creation of a list of recommended measures for all indicators. Expansion and maintenance of NCCOR, which includes many measurement instruments, can be a first step toward development of a list of standard measures. Training sessions can be conducted via webinars, videos, in-person sessions, and PowerPoint presentations. All training sessions to implement the National Obesity Evaluation Plan would include criteria for achievement of appropriate skill levels and be linked to continuing education credits for various professions (e.g., registered dietitians, certified health education specialists).
Technical assistance, which includes assistance for selection of appropriate measures, development of study designs or logic models, or troubleshooting of problems in the field can be administered through one or several training centers and provided to federal, state, territorial, and local groups. CDC has a mandated role and long history of providing technical assistance to the states on monitoring and surveillance (Drehobol et al., 2012). Expansion of its programs, perhaps through the Prevention Research Center network, would leverage current resources and expertise. In addition, the National Center for Health Statistics could be expanded to provide more technical assistance, especially to replicate NHANES-type measures more broadly or at the state level. Other existing resources for training that can be leveraged include the NIH's Training Institute for Dissemination and Implementation Research in Health and other existing resources for ongoing measurement and evaluation supported by organizations like RWJF (e.g., Healthy Eating Research, Active Living Research) (NIH, 2013; RWJF, 2013a,b).
As detailed in Chapter 2, evaluation users need timely and relevant feedback of information from monitoring, surveillance, and summative evaluation efforts to evaluate and promote incremental progress in achievement of intervention goals (Garney et al., 2013). A recent survey of CDC's Surveillance Science Advisory Group (SurvSAG) and scientists on their distribution list found that only one-third of respondents agreed that data are analyzed and disseminated in a timely fashion (Thacker et al., 2012). The federal government developed the Health Indicators Warehouse (HIW) (National Center for Health Statistics, 2013) to facilitate access to and use of data associated with Healthy People 2020 indicators and other related health indicators. Data from the HIW are categorized by topic, geography, and initiative, and reports can be generated via a Web-based, interactive system. Ideally the HIW could be expanded to include more features and data, as well as efforts to decrease duplication of data systems.
Another potential method of providing feedback to data users is through the Community Commons, which links geographic information systems data to provide an interactive mapping and networking platform (Community Commons, 2013). Although the Community Commons primarily focuses on communities (see Chapter 7) and place-based initiatives, it does have the capacity to produce federal-level mapping. This model for data utilization includes easy-to-understand maps and graphics that can be used as discussion points for communities and organizations. This concept can be further expanded by the use of federal or community “dashboards” that provide information for the jurisdiction or community compared to a benchmark or goal metric. Metrics can also be illustrated at the federal and/or state level through “report card”-type maps, such as those on the website of the Data Resource Center for Child and Adolescent Health (The Child and Adolescent Health Measurement Initiative, 2012), in which state levels of selected indicators are color coded.
At the national level, information from the National Obesity Evaluation Plan should be used to refine programmatic initiatives, assess effectiveness of policies and other interventions, identify any unintended consequences, and determine cost-effective strategies to prevent obesity. Data from the National Obesity Evaluation Plan could help to further elucidate the evidence base for the APOP recommendations and suggest new environmental and policy strategies or directions for future obesity prevention efforts.
Federally funded grants, initiatives, and programs through NIH, CDC, USDA, and other governmental agencies can provide additional data for the National Obesity Evaluation Plan. For example, competitive programs for obesity prevention, such as the Communities Putting Prevention to Work (CPPW) (Bunnell et al., 2012; CDC, 2013d) and Community Transformation Grants initiatives (CDC, 2013e) can provide data that reveal the impact of intervention strategies from APOP. The CPPW included programs in 50 communities from 2010 in 2-year initiatives; of these programs, 28 focused on obesity prevention, 11 focused on smoking prevention, and 11 focused on both obesity and tobacco use (Bunnell et al., 2012). A national evaluation of the programs after 12 months indicated a mean reach for obesity-prevention initiatives of 35 percent of the population, with progress on approximately one-third of the proposed obesity and tobacco prevention strategies. Although data on reach and progress on proposed goals have been collected, further summary data are not available, largely because of the lack of standardized measures for policy, systems, and environmental interventions, as well as the variety of program efforts proposed. A recent funding opportunity announcement 12 by CDC provides a wealth of opportunity for funding, guidance, and support that could create evaluation results that are more comparable with identical indicators. The State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity, and Associated Risk Factors and Promote School Health Programs 13 provides an outline of activities and strategies (using a logic model approach) to prevent and reduce risk factors associated with childhood and adult obesity, diabetes, heart disease, and stroke. The use of standardized protocols and measures for a key set of indicators (see Tables 6-2 and 6-4) could provide aggregation of data to inform larger dissemination or policy interventions.
An innovative and evolving National Obesity Evaluation Plan will need a provision for development, testing, and incorporation of new, alternative, and emerging methods of data collection that have the potential to capture data in real-time with greater precision. These contributions will necessarily, or at least most usefully, come from actual evaluations of national, state, and local programs as they attempt to use the existing surveillance systems and to adapt them to emerging programs and evaluation needs. In the CDC survey of the SurvSAG members, only about 20 percent agreed that CDC had the ability to adopt new surveillance methods in a flexible and competitive manner (Thacker et al., 2012). Emerging trends in data collection include use of the “quantified self,” in which participants track their own health information (Swan, 2009); the use of cameras and related equipment to determine food intake (Sun et al., 2010) and document food and physical activity environments; and real-time data capture through smart phone technology (Freifeld et al., 2010; Matic et al., 2011). Social media may also be a platform for surveillance: a recent study found an association between neighborhoods where a higher proportion of the population documented interest in television shows on Facebook and obesity prevalence (Chunara et al., 2013).
Enacting a comprehensive National Obesity Evaluation Plan will require considerable resources. None of the activities detailed in the Plan (see Box 6-2) can be accomplished without considerable and concerted effort. Acknowledging the need for cost containment, the Committee sought to identify potential efficiencies when developing the Plan, including
Use of an existing federal-level obesity task force/entity or combination of existing ones if possible, rather than formation of a new group to oversee and coordinate implementation of the plan;
Focus on maximizing and coordinating existing surveillance systems, when possible, to leverage resources;
Use of available indicators that can have multiple uses and stakeholders (e.g., fruit and vegetable intake as an indicator for obesity as well as cancer prevention); and
Identification and elimination of duplication in surveillance systems or indicators.
Despite attempts to minimize costs, the Committee realizes that adequate evaluation efforts require serious commitments of political will, coordination, and resources. Evaluating the progress of obesity prevention must be prioritized over other national health issues and interests. Federal institutions leading national surveillance systems, each with their own purposes and stakeholders—but none with a singular focus on obesity—must prioritize obesity-related indicators above other long-held interests. Decision makers must make difficult choices and champion some indicators over others, so that respondent burden is not excessive and survey administration costs are not prohibitive. Newly developed indicators must be rigorously tested and compared in order to identify those most valid and reliable. Finally, this plan is meant to be iterative with a feedback loop which involves sharing evaluation results, stakeholder feedback, and implementation of changes based on the evolving data. This process itself can lead to a more streamlined evaluation process, where indicators that are intractable or already achieved may be culled to focus on indicators and surveillance systems that are more sensitive to change and have better relations with outcome/impact measures.
The APOP report (IOM, 2012a), TWOTN videos, 14 and Chapter 1 of this report all clearly document the devastating current and future economic and health effects of the high prevalence of overweight and obesity in the United States. Implementation of the National Obesity Evaluation Plan requires that decision makers and the general public are aware of the magnitude of the problem, the economic consequences, the relationship of obesity to other chronic diseases and disability, and the role that evaluation will play in monitoring progress in efforts for obesity prevention. It will also be important to adequately disseminate these messages to all stakeholders and to obtain adequate buy-in at the national level, as well as at a grassroots level.
Some of the challenges and opportunities for measuring progress in obesity prevention can be illustrated using a case study for the evaluation of TWOTN (see Box 6-3). In this example, the existence of a more robust national infrastructure for evaluation would have allowed for better baseline measures, canvassing of other social media campaigns, and measurement of impacts for TWOTN. TWOTN is offered here as the example of challenges and opportunities for measuring progress to address the Committee's charge of identifying measurement ideas that can determine the impact of the national aspects of the campaign (see Chapter 1 for background on the purpose and components of the campaign).
Opportunities for Putting the National Obesity Evaluation Plan into Practice: Evaluating the National Components of The Weight of the Nation Campaign. One way to evaluate the national component of The Weight of the Nation (TWOTN) campaign (see Chapter (more. )
Almost all states have individual plans for obesity prevention and control, physical activity, and/or diet (see Appendix Table F-3). The comprehensiveness of these plans varies, as do the resources and infrastructure for monitoring and summative evaluation. Several states have established various levels of state evaluations, many as a result of CDC funding (CDC, 2012b).
At the state level, the most significant and well-established surveillance systems are BRFSS, YRBSS, and PRAMS (see Appendix Tables D-1 and F-2), and, until 2012, PedNSS and PNSS conducted by CDC. The BRFSS relies on random-digit dialing and telephone interviews for self-reported data on adults' weight and height, diet, and physical activity, among other health-risk data (CDC, 2013b). BRFSS data are available every 2 years by state level and can be aggregated to the national level. BRFSS data are also available at selected city and county levels, through SMART regions, which have at least 500 respondents in approximately 170 areas (CDC, 2011).
The YRBSS includes national school-based surveys of high school students (grades 9–12) as well as state, territorial, and local school-based surveys conducted by health and education agencies (CDC, 2013a). As with the BRFSS, data are self-reported, which can be problematic, especially for height and weight (Morrissey et al., 2006; Stommel and Schoenborn, 2009). YRBSS information is also collected on students' health risk behaviors, which include dietary habits, weight loss practices, and physical activity.
CDC provides funding and infrastructure for core indicators of the BRFSS and the YRBSS, plus technical assistance, to every state. States can elect to oversample certain populations, add additional populations, or expand the core indicators with other cores or individualized assessments; however, these enhancements can be costly. Nevertheless, if resources are available, then this model may be useful for development of State Obesity Evaluation Plans, as the data collection infrastructure allows for state-level data, as well as the capability to aggregate up to the national level.
Several states have developed their own surveillance and summative evaluation systems. These vary in infrastructure, methodology, and focus. For example, larger states often need to rely on probability-based sampling to collect population-level data, while collection of data at a census level is feasible in smaller states. Several of the surveillance systems in place address obesity and related risk factors in school-aged children, but not necessarily in preschool children or adults. A quantification of states who conduct surveillance and summative evaluation activities for obesity prevention efforts is difficult, because there is no central data repository for these measures, and most state data are found in state reports or online, rather than in peer-reviewed journals.
California is one state that has developed its own obesity prevention plan that includes an evaluation component. Developed through legislative mandate, the 5-year plan, run by the California Department of Public Health, focuses on environmental and policy initiatives to achieve the following population-level behaviors: increase intake of fruits and vegetables, decrease intake of sugar-sweetened beverages and energy-dense foods, increase physical activity, reduce television viewing time, and increase breastfeeding (California Obesity Prevention Program, 2010). The overarching evaluation goal is to create and implement a statewide monitoring, surveillance, and summative evaluation system. The 5-year objective is to measure progress toward obesity prevention in California by assessing overall health, health behaviors, and policy and environmental change. Ongoing efforts are focusing on identifying California- and county-specific data sources and indicators of progress in obesity prevention available since the late 1990s, such as the California Department of Education's FITNESSGRAM® data on BMI and physical fitness collected annually from 5th, 7th, and 9th grade students 15 and the annual California Healthy Kids Survey on nutrition and physical activity behaviors collected from 5th, 7th, 9th, and 11th grade students, 16 the biennially administered California Department of Public Health surveys 17 on dietary practices and physical activity assessment in adults (California Dietary Practices Survey), adolescents (California Teen Eating, Exercise, and Nutrition Survey), and children (California Children's Healthy Eating and Exercise Practices Survey), which also include questions about school and home food and activity environments, and the ongoing California Health Interview Survey administered by the University of California, Los Angeles, on select dietary behaviors in children, adolescents, and adults. 18
Texas conducted a statewide evaluation of school-based child obesity, nutrition, and physical activity through the School Physical Activity and Nutrition (SPAN) survey (Hoelscher et al., 2004). Survey instruments for SPAN were developed and evaluated for psychometric properties through funding from CDC and USDA (Hoelscher et al., 2003; Penkilo et al., 2008; Thiagarajah et al., 2008). Conducted in 2000–2002, 2004–2005, and 2009–2011, SPAN provides state and state-regional estimates of child overweight and obesity for children and adolescents in grades 4, 8, and 11; these grades were selected to represent approximately pre-pubertal, pubertal, and post-pubertal time periods. Evaluation at the regional level within the state provided data that supported the effectiveness of community-wide obesity prevention initiatives in El Paso (Hoelscher et al., 2010), as well as associated diet and activity patterns (Ezendam et al., 2011). SPAN data also includes surveys on school programs, environmental factors related to nutrition and physical activity, and school-level policies.
Arkansas also has implemented a statewide evaluation of obesity prevention policy efforts in schools (see Chapter 2).
The advantages of the state monitoring, surveillance, and summative evaluation systems include an existing infrastructure through the BRFSS and the YRBSS, the possibility of measurement and data for state- and regional-level stakeholders, the ability to focus on state-specific context or constructs, using core indicators that can be compared to federal benchmarks, and the “natural experiment” afforded by the comparison of state population changes in relation to state variations in policies and other interventions. In many states, lawmakers are more likely to respond to data derived from local sources, as opposed to more global national-level data, and to respond to invidious or favorable comparisons between their state and some others.
Three more benefits of using state-level surveys or data collection infrastructures are (1) they often can be implemented more quickly than federal-level assessments; (2) they can be used to guide the development of national surveillance and summative evaluation efforts, besides serving as inspiration or stimuli for action in other states; and (3) probably most important, state-level data can often be a bellwether for national trends and provide early indicators of progress or backsliding that might not show up in national data trends for years. Paying attention earlier in the development of trends is a lesson learned from the lag between the early outbreaks and gathering signs of the obesity epidemic in the 1970s and national action that did not gain traction until the 1990s (Gortmaker et al., 1990; IOM, 2004).
The state-level evaluation plans have several disadvantages, including the cost, and consequent lack of objective data; a relative paucity of methods comparable to the National Obesity Evaluation Plan; and a relative lack of resources and infrastructure to develop and maintain state systems comparable to the national monitoring/surveillance systems. As mentioned previously, states vary greatly in size, available resources, political climate, and prioritization of health surveillance needs and obesity as a problem. Effective data collection requires state-level benchmarks, coordination at the state level, resources to collect the data, and resources/infrastructure to report results back in a timely manner.
In general, evaluation of progress in obesity prevention at the state level ideally would be modeled after the National Obesity Evaluation Plan (see Box 6-2), which would allow states to compare state-level data to national data and guidelines (e.g., state adult obesity prevalence compared to the national adult obesity prevalence). Although patterning state evaluation plans after the National Obesity Evaluation Plan may be an appropriate and efficient first step, state monitoring/surveillance systems will likely need to include questions that address specific indicators or issues in specific state priority populations. Because states tend to be more nimble than the federal systems, and because states often have distinct populations that require changes in measurement protocols or instruments, it is anticipated that exemplars at the state level might serve as a resource or “pilot” for addressing gaps at the federal level identified in the National Obesity Evaluation Plan. These new protocols or instruments can provide new indicators or measurement techniques that can later be adapted for national monitoring/surveillance systems.
As with the National Obesity Evaluation Plan, states would ideally identify an obesity task force that would reside in the state health department and report directly to the state commissioner of health, or even to the governor as a multi-agency state task force. This task force needs to be comprised of state department heads and stakeholders inclusive of all geographic areas of the state. State health goals would provide benchmarks and guidelines for indicators, although most state obesity plans likely will model these after federal recommendations. Detailing a process to establish priorities and a timeline for implementation would further strengthen the plan.
An assessment of current monitoring, surveillance, and other summative evaluation efforts at the state level would be the next step in the State Obesity Evaluation Plan; this is expected to be a less intensive undertaking than detailed in the National Obesity Evaluation Plan. While conducting an inventory of state evaluation methods and systems, it is important to determine if state-level indicators are consistent with those at the federal level (see Table 6-4). Thus, harmonization of indicators and data collection systems would include comparisons with both federal and state measures and infrastructure.
Some states will need to develop capacity to implement a State Obesity Evaluation Plan. In addition to consistent funding to support evaluation activities, states will need to cultivate a workforce with expertise in sampling, statistical analysis, and public health. Partnering with local state universities may be a potential solution for addressing workforce needs. In addition, new questionnaires and survey items may need to be developed to address special state populations, and technical assistance may be required as well. CDC has traditionally provided technical assistance to states for surveillance and other summative evaluation efforts through the Division of Adolescent and School Health, Prevention Research Centers, the BRFSS, and the YRBSS.
An important part of the State Obesity Evaluation Plan is the timely feedback to state stakeholders. Again, the resources at the state health agency, as well as state mandates, may determine how quickly data can be collected, analyzed, and disseminated. At the state level, newer methods such as crowd sourcing or individual data collection might be easier to implement than at a national level and may provide local data; however, for this to be viable, it will be necessary to develop more “off the shelf” utility products that can be easily implemented with more limited staff and resources.
One limitation of state-level data is the inconsistency of monitoring/surveillance activities due to fluctuations in state budgets and unfunded mandates. For example, measurements that are obtained through schools, such as Fitnessgram®, 19 can be difficult to sustain consistently over time without allocation of resources.
Regional efforts related to evaluating progress in obesity prevention may be defined as those that are applied to a discrete area of common interest, such as the service area of a health plan, a geographic area across multiple states where an employer has worksites or a stream of migrant workers travel, or aggregations of counties with population characteristics in common (e.g., the Appalachian region across North Carolina, West Virginia, and Pennsylvania). Regions may not be confined by state borders or geography and may be defined by industry market interest, by health disparities, or by other health-or disease-related factors. As a result, evaluation efforts for a regional audience may differ from national- or state-specific efforts.
One efficient and relatively low-cost method of obtaining good quality data on obesity prevention efforts and outcomes is through health plans. A health plan is likely to be interested in knowing the prevalence or incidence of obesity among its members and whether they vary in obesity-related care by subregions across its service area, by care delivery systems among its contracted network, or even by clinic where members receive their care. Whereas a health plan may be informed by state-specific data, such data may not be specific to its membership. Plan-specific data may come from a variety of sources, including EHRs, clinical screenings, health impact assessments, the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), and member surveys. For example, HEDIS consists of 75 measures across 8 domains of care and is used by more than 90 percent of U.S. health plans; these data could be useful for obesity prevention efforts if aggregated across regions (NCQA, 2013).
The America's Health Insurance Plans provides updates on obesity for its member plans and includes recommendations on addressing obesity (America's Health Insurance Plans, 2008). Similarly, the Alliance of Community Health Plans provides its member plans with obesity-related updates and applications (ACHP, 2013).
BMI data can be efficiently collected via EHR and, when collected this way, have been shown to be as accurate as other population-based surveys, such as the BRFSS (Arterburn et al., 2010). Health plans also use membership surveys to document a variety of health- and care-related variables, including obesity, as well as the relationship of obesity to health care costs, disease diagnoses, and pharmacy-related concerns (Pronk, 2003). Often, these data are publicly displayed on health plans' websites (e.g., see HealthPartners, 2011). NCQA, through HEDIS, reports on obesity-related metrics (NCQA, 2012). Also, health assessment may be used to monitor obesity-related data on subgroups of health plan members. Additional information related to health plans and information that can be used to evaluate obesity prevention interventions can be found in Chapter 2. In essence, with coordination, health plans can serve as efficient and relatively low-cost regional surveillance data sources.
In the context of the worksite setting, employers increasingly use workplace screening programs to document and monitor BMI and obesity, as well as related health risks (Framer and Chikamoto, 2008; Goetzel and Ozminkowski, 2008). In addition, obesity-related claims may be used to gain a better understanding of the costs and disease burden associated with excess weight (Colditz, 1992; Finkelstein et al., 2009), locally or regionally.
Implementation of a National Obesity Evaluation Plan to assess the APOP strategies would enhance the ability of the United States to demonstrate progress in obesity prevention efforts, provide guidance on gaps in the extant programs and policies, and redirect use of resources. Elements of the National Obesity Evaluation Plan were developed to maximize existing monitoring/surveillance systems and incorporate metrics that are similar to those in other plans, such as the WHO framework. Objectives of the plan include the appointment of a federal obesity evaluation task force with accountability to coordinate a monitoring, surveillance, and summative evaluation system with rapid feedback and utilization by stakeholders, increased resources for monitoring/surveillance and summative evaluation, and creation of new and innovative methods to take advantage of current technological capacity. Settings that were identified as key areas of focus in the APOP report, such as worksites and child care centers, should be included in current monitoring/surveillance systems. Physical activity measures should be added or strengthened in the U.S. monitoring/surveillance systems, and new measures to assess social and built environments should be included as well.
Barriers to the implementation of the plan include costs, competing priorities, and the efforts involved with coordinating the separate components of the evaluation systems into a harmonized whole. Addressing the barriers will require that both decision makers and evaluation users are aware of the consequences of obesity, as well as acknowledgment of the role of evaluation in the assessment and development of obesity prevention interventions.
Implementation of the State Obesity Evaluation Plans will need to be aligned with the National Obesity Evaluation Plan to allow for comparability; however, state-level evaluation activities should be flexible enough to adapt to unique populations and state characteristics. Regional evaluations can take advantage of new initiatives to coordinate electronic health data to provide estimates for specific groups that extend across states.
Implementation of a National Obesity Evaluation Plan is an essential part of the implementation of recommendations in the APOP report. A coordinated monitoring/surveillance system would greatly enhance the ability of the United States to track intervention efforts across different environments, as well as to determine if our current efforts are preventing obesity or if a different direction is warranted. Chapter 10 provides seven recommendations (and a set of potential actions and actors) to support the implementation of the components of the National Obesity Evaluation Plan.
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The Weight of the Nation is a coordinated, multi-media, multi-organizational campaign designed to help create awareness, inform, and motivate action to slow, arrest, and reverse the trend of obesity across the United States.
Includes but not limited to efforts in the following federal agencies: Corporation for National and Community Service; Departments of Agriculture, Commerce, Defense, Education, Health and Human Services, Interior, Labor, Transportation, and Veteran Affairs; Domestic Policy Council; Environmental Protection Agency; Federal Trade Commission; General Services Administration; and Office of Management and Budget.
In NHANES, diet is assessed by 24-hour recall, which is the gold standard for assessing population-level intake of calories, macronutrients, micronutrients, and foods/food groups, as opposed to other monitoring and surveillance systems, which generally rely on food frequency—type questions about select foods/food groups.
Appendix Table F-2 includes the PRAMS, a potential data source for information on diet and activity during pregnancy and pre-pregnancy weight.
Selected indicators, such as breastfeeding and maternal BMI, that may have been collected in PNSS, can be collected from parents through the information collected from the 2003 proposed birth certificate changes (CDC, 2012a; Martin et al., 2012).
Existing regional, county data could be aggregated, or sampling could be improved.
For example, YRBSS does not collect data for all states.
See http://www .ihe.net (accessed November 11, 2013).
The Department of Health and Human Services proposed changes to the birth certificates in 2003.
