Post on 05-Sep-2020
transcript
Prevalence of Overweight & Obesity in African American
Adolescents in Baltimore, Maryland
Angela Silveira MD, MPH
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EXECUTIVE SUMMARY
Obesity is a rising issue in the United States with nearly 60 % of the total population being obese1.
Obesity places a person at risk for heart disease, and 61 % of obese children have at least one
additional risk factor. Adolescents battling obesity are at a high risk for co-morbidities such
hypertension, polycystic ovarian syndrome, non-alcoholic fatty liver disease, orthopedic
complications, and sleep apnea2. In Baltimore city, with 63% of the demographic being African
American/Black, 34% of these adolescents are greatly affected making this an emerging public
health problem1. Key factors contributing to this issue include biological factors (e.g., birth weight,
sex, and ethnicity); behavioral factors (dietary intake, physical activity and screen time); as well as
other individual, family, community and political determinants. There are currently evidence-
based prevention strategies in place within Baltimore, however improvement is necessary. These
modified interventions require tailoring to the specific needs of this population as well as
collaborations with stakeholders including the Baltimore City Health Department and public
schools. In precise monitoring and evaluation of our multi-faceted program implementation, this
intervention will deliver exceptional deliverables in reducing the percentage of overweight in a time
frame of 3-5 years.
PROBLEM DEFINITION
Based on data from the last decade, the prevalence of obesity and overweight in
adolescents remains high, specifically among African-American/Black adolescents living
in Baltimore City, MD, mirroring that of national trends in OW/OB.
The problem definition is focused on adolescents rather than the entire population of overweight
and/or obese population in Baltimore, Maryland since targeting obesity in adolescence will reduce
obesogenic associated diseases in adulthood such as diabetes and hypertension. We chose this
time, 2007-2017 mainly due to the availability and quality of data from agencies such as the
Baltimore City Health Department and Centers of Disease and Control Prevention (CDC).
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MAGNITUDE
The rate of obesity has peaked globally. Of the worldwide population, a third of the US population
is obese3. In 2007, the number of overweight and obese adults in the country totaled 60% with a
prevalence of obesity affecting 12.7 million children and adolescents today4. The prevalence of
obesity in the US among 12-19-year-old African Americans is 20.5% in comparison to 8.9% of 2-
5-year-old children. According to the U.S. Census, 63.3 percent of Baltimore's population in 2013
was black5. In Maryland, 38.1% of the African American/Black population is obese and 33.6% are
10-17-year-old adolescents ranking Maryland as the 13th obese state in the country. In 2007,
Baltimore City’s obesity rate of 35 percent is higher than their counterparts in Maryland and of the
U.S. making this problem a high- rise priority6.
Being obese or overweight can be determined through Body Mass Index (BMI), which is
calculated using the child’s weight and height, and is a reliable measure of body fat. BMI is
compared through percentiles, which represent the normal size and growth patterns of children
according to their gender and age. Overweight children are between the 85th and 95th BMI
percentiles of their age, and obese children are above the 95th 7. If adolescent obesity propels into
adulthood, adolescents with a higher BMI will have 30% higher rates of mortality as young and
middle-aged adults, with an increased risk of multiple comorbidities in adulthood such as diabetes
and hypertension 8. The Bogalusa Heart Study tracked 2,400 5- to 14-year-old children for a mean
of 17 years and found that obese black children were even more likely to remain obese as adults
(83%) than obese white children (68%)9.
Direct indicators such as the percentage age of students that are obese and overweight in Baltimore/
percentage of age nationally and the percentage of adolescent obese and overweight /percentage of
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age nationally. Indirect indicators selected are perception of one’s own body weight and consuming
sugar sweetened beverages (SSBs). During the 2017-2018 school year, there were 16,964 students
enrolled in grades 6 to 8 and 20,764 students enrolled in grades 9 to 12 (Baltimore City Public
Schools, 2017). Of these numbers, 80.1 percent are African American (Baltimore City Public Schools,
2017). If the prevalence of obesity and overweight remained constant among Black high school
students in Baltimore from 2015 to 2017, the number of obese Black high school students would be
2,827, and the number of overweight Black high school students would be 2,960. Similarly, if the
percent of Black students who perceived themselves as overweight remained constant from 2014 to
2017, the number of students would be 2,595. The number of Black high school students estimated
to drink at least one serving of soda per day is 4,840. Some limitations to these indicators include
not measuring weight and height, differing methodologies based on age of student, self-
identification and only capturing students in the public-school system.
KEY DETERMINANTS
The key determinants are divided into six categories: Biological, Behavioral, Individual, Family,
Community and Political.
BIOLOGICAL:
There are several biological factors contributing to the rise of obesity in adolescents that is
supported by extensive research. The following list of factors play a significant role in obesity in
adolescents: breastfeeding, birth weight, exposure to gestational diabetes mellitus (GDM), sex and
ethnicity8,10,11.
BEHAVIORAL:
Dietary intake, physical activity, screen time and sleeping hours were all significant factors that
contributed to being overweight and/or obese in adolescents. Lack of physical activity was a main
contributor as well as increased screen time (> 2 hrs./day) through watching television, playing
video or computer games 12. Dietary intake such as selection of a larger portion size and skipping
a meal, particularly breakfast, is also linked with obesity11.
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INDIVIDUAL
This includes factors like: food preferences (sweet or salty), food knowledge (caloric/nutritional
content), psychological factors such as emotional eating and addictive behavior are other factors
contributing to obesity in adolescents13,14. Emotional eating caused by hormonal imbalance during
this phase, addictive behavior (alcohol, tobacco, marijuana use). Alcohol and tobacco did not have
significant associations in this age group, however, consistent or increased use of marijuana from
aged 12 to 18 years was associated with an increased risk of obesity in young adulthood13.
FAMILY
These factors include eating practices (preparing meals and designated dinner time), family
income( lower SES) and caregiver obesity (10-12 more at risk if both parents are obese) 11,15-17.
COMMUNITY
These factors include the built environment (higher crime area where disadvantaged and minority
children live in more, low-safety environments, and deteriorating neighborhoods not promoting
physical environment to exercise)18, food availability (food deserts, less accessibility to grocery
stores that carry fresh produce, increased obesogenic areas that have fast foods)19,20 and SSB tax (
preventing purchase of SSBs particularly in adolescents)21.
POLITICAL
These are all school based and community based interventions that are currently in place or have
been implemented2,22-24.
CONCEPTUAL FRAMEWORK
The conceptual framework for this presentation is included below (Figure 1). It is similar to a socio-
ecological model which helps us to creatively visualize different levels to intervene at. It is also
comprehensive in details of determinants in each category. All the factors included in the
framework are also evidence-based. The goal was to maintain visual clarity and comprehension.
The limitation of the framework is that it is specific to adolescents and does not display obesity
through a life course perspective. In addition, causal and non-causal factors are not illustrated.
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Figure 1:
KEY STAKEHOLDERS
A stakeholder is an individual or group that has an interest in an issue. The following is a
list of some stakeholders with interest and possible concerns about obesity in African American
adolescents in Baltimore city:
Local agencies: local partnerships, department of education, Baltimore City Health
Department, Baltimore City public schools in Maryland
School staff: included in curriculum, teachers, sports facilitators,
Local food distributors: source of fruits and vegetables
Media team: campaign organizers, newsletter/brochures production
Dietician: in charge of nutritious recipes
Parents: to help encourage students to participate in the event
Those affected are in school adolescents and their parents. Those interested in the
evaluation results can be the following: planning committee, local agencies, researchers,
Baltimore community, health insurance companies, professional societies.
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Although these are active participants in providing resources for preventing obesity, some
stakeholders may be hesitant in investments over a longer time periods due to costs
necessary for sustainability.
IDENTIFICATION OF INTERVENTION AND PREVENTION STRATEGIES
B’MORE HEALTHY COMMUNITIES FOR KIDS (BHCK)
BHCK was spearheaded in Baltimore in 2014 and was initiated as a multi-level initiative to work
directly with low-income neighborhoods where there is limited accessibility to fresh produce and
other nutritious staples. Some strategies included: working with carry outs to increase access,
creating cost-effective collaborations between smaller stores and wholesalers and promoting
cooking healthier meals and sharing food knowledge.
RETHINK YOUR DRINK
The Baltimore City Health Department launched a public health education campaign called
Rethink Your Drink that required warning labels on all SSB advertisements, restaurant menus, and
in any store selling SSB’s.
WHAT MAKES A LUNCH
A free meal program (breakfast and lunch) for all students seeks to address food insecurity and
remove cost as a barrier to healthy food access. The meal consists of choosing a fruit and vegetable
and milk for lunch.
PLANET HEALTH
Planet Health an interdisciplinary curriculum in Boston, was integrated with physical activity (PA),
nutrition lessons and a two-week Power Down campaign to decrease screen time. In addition,
newsletters with PA and nutrition information to involve parents, school administrators, and staff
in reducing adolescent obesity25. The cost of the program was $33,677 or $14 US dollars per student
per year, with the program preventing an estimated 1.9% of the female students (5.8 of 310) from
becoming overweight adults. These findings translated to a cost of $4305 USD per QALY saved and
a net saving of $7313 USD to society26. Considering the success of the program, our interdisciplinary
curriculum would have a similar approach and work towards a similar goal.
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ALTERNATIVE INTERVENTIONS
The primary decision criteria used for selecting these interventions were effectiveness, political will,
and sustainability (see Figure 2. Decision matrix). Other interventions considered included a policy
intervention through a local SSB tax (1% per fluid oz.). The strength of this is, it is a passive
intervention that would provide primary and secondary prevention and economic disincentive and
enforcement. It would also an evidence-based association with reduction in obesity; the tax would
provide financial support to more obesity prevention/treatment programs. Some weaknesses would
be low social and political will and low- cost feasibility. It also ignores biologic and individual
determinants.
Another alternative intervention is a community based (programmatic) intervention to increase
healthy food options in corner stores and take-out food services. It is an active intervention with
primary and secondary benefits including education, engineering and economic incentives (for
store owners). Strengths of this intervention include high social will, increased knowledge and
addressing many key determinants. Weaknesses include difficulty in determining cost feasibility
and sustainability which is dependent on many players.
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PROPOSED INTERVENTION & IMPLEMENTATION
The proposed intervention will be a multi-level and multi-component intervention consisting of an
interdisciplinary curriculum, food environment and physical activity to lower the prevalence rates
of overweight and obese African American adolescents in Baltimore City over a 3- 5-year period. It
will be an active program intervention involving education and engineering. Implementation will
include media campaigns where students can be connected, engaged and informed through media
portals like Facebook, Twitter and Instagram. Parents and teachers will be informed through
communication strategies like newsletters, brochures, PTA meetings and the Baltimore community
through television and radio to raise awareness.
There will be a pilot intervention with 3 public middle schools and 3 public high schools in
Baltimore City to expand to all middle and high schools incrementally. The first step would be to
identify potential pilot schools with Baltimore City Health Department (using life expectancy,
obesity, income, food access data and BHCD’s knowledge of previous piloted interventions in
schools) and hold informational meetings and focus groups with interested school administrators.
Workshops on curriculum education will be held and a curriculum specialist will be hired for data
collection as an intervention liaison between schools and JHU--using model of community-based
participatory research27. The first step will mirror Planet Health and extend to only the middle
school due to differing curriculum.
Our second level, improving the food environment, is already currently in place for elementary
schools. USDA Fresh Fruit and Vegetable Program (FFVP) has funds designated to provide fresh
fruits and vegetables as snacks ($50-75 per student per year) to eligible elementary schools. We will
replicate this intervention in middle and high schools with city partnerships and make minor
modifications such as inclusion of:
Fruit and vegetable distribution: twice per week.
Recipes developed by dietician
Implementation through partnership with Baltimore organizations working in food access.
Improving the food environment has been successful in several states such as 14 FFVP participating
Arkansas elementary schools that demonstrated a 3% decrease in obesity rate as well as a 1.8%
reduction in overweight rate. Reductions in BMI and school level obesity rates are attributed to
FFVP participation and are large enough to be economically meaningful5.
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The final part of the intervention is promoting the physical activity environment before school,
after lunch and after school. This includes increasing the availability of physical activity equipment
and increasing physical activity supervision. An RCT of 48 middle schools in San Diego showed
significant intervention effect for physical activity for the total group (p <0.009) and boys (p <0.001),
but not girls (p <0.40)28. In addition to this, a review of disparities in physical activity and sedentary
behaviors in US children and adolescents states that because physical activity in schools (vs
recreation in the community) represents a greater proportion of physical activity for low-income,
communities of color, policies that increase physical activity in schools (and ensure existing
policies) and recreation opportunities may help address disparities in physical activity behavior29.
This will include designing physical activity opportunities specific to the selected schools through
focus group direction and supervision of school staff to guarantee success. Physical activity levels
are monitored at the start and end of each school year for the span of the program using surveys.
Physical activity will also be mandatory for 60 min/day with flexibility in timing: before classes,
after lunch, and after school hours. Nutrition education will be incorporated into the school
curriculum targeted to ensure each student gets 10 to 12 lessons per year. Students will be taught
how to make healthy food choices, with an emphasis on healthy fat, that contribute to a well-
balanced diet and selecting beverages without added sugars or artificial sweeteners. Financial costs
would be like Planet Health ($7,360 for 3 middle schools), FFVP ($40,000 for 3 middle schools
$121,000 for 3 high schools) and PA equipment ($500/school) highly feasible costs for the year.
Funding sources from Baltimore City Health Department, CDC, Johns Hopkins Global Obesity
Prevention Center, Hungry Harvest and Capital Area Food Bank.
A multi-component intervention was selected because these interventions are found to be the most
promising. School support used to facilitate about 30% of interventions and may be a support for
sustainability of interventions. Parents involved in 90% of interventions studies and are considered
key actors in the physical activity and nutrition of children26. When combined in a school setting,
physical activity and nutrition components show higher efficacy when targeting multiple behaviors
and environments in those with longer duration22. Some barriers can include long term
sustainability after the high school children graduate, developing better methods for short term
progress to yield tangible results, and providing continuous fiscal stability (funds for staff,
equipment and materials) necessary for both implementation and sustainability. In addition,
training of staff and having ongoing consultation may be an issue if there is a substantial amount
of turnover in teachers and school administrators.
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EVALUATION
Key stakeholders that will be highly interested in the evaluation plan will be those that are
providing direct funding sources such as the Baltimore City’s Health Department, CDC’s child and
adolescent sector, and JH Obesity and Prevention Center.
Process evaluation can be accomplished by deciphering how many parents (percentage) are aware
of the intervention strategies through the number of newsletters distributed to them, surveys sent
home and returned completed, and the number of parents present at PTA meetings. Another
evaluation method would be calculating the percentage of students using facilities purchased
through the program for physical activities in school through student surveys and attendance
records for the programs physical activities. This would evaluate if students are utilizing facilities
purchased through the program for physical activities in school.
The two main outcome evaluations are firstly to determine if there is an increase in physical activity
among adolescents. This can be captured by determining the percentage of students who have
increased their physical activities through pre-and post-Fit check records and focus groups.
Secondly, determining if the percentage of students who are overweight and obese has reduced
through the above evaluations.
CONCLUSION
Obesity is one of the most pressing issues facing our youth today. Obesity continues to
disproportionately plague ethnic minorities such as the African American population at higher
rates. In Baltimore city with more than half of the population identifying within this ethnic group,
the city has taken great strides towards raising awareness and implementing programs tackling
obesity, however there is an urgent need for improvement. Within the Baltimore community,
dietary patterns and perceptions are molded by biological, behavioral, individual, family,
community, and political beliefs. It is essential to delve deeper into societal structural influences to
improve the quality and access to healthy food. A multidisciplinary approach is key to target obesity
in adolescents while maintaining sustainability. It is a working effort in partnership with all key
players to bear witness to change. With the continued rise of this public health burden, it is our
responsibility as adults to protect our adolescents from co-morbidities haunting our current health
and their future well-being through implementation of school and community based programs.
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REFERENCES
1. Mitchell NS, Catenacci VA, Wyatt HR, Hill JO. Obesity: Overview of an epidemic. Psychiatr Clin
North Am. 2011;34(4):717-732.
2. DeMattia, L., & Denney, Lee. Childhood obesity prevention: Successful community-based
efforts. 2008; The ANNALS of the American Academy of Political and Social Science (615(1)):83-
99.
3. Murray, C. & Ng, M. Nearly one-third of the world’s population is obese or overweight. Institute
for health metrics and evaluation. 2014.
4. Popkin, B, & Gordon-Larsen, P. The nutrition transition: Worldwide obesity dynamics and
their determinants. International journal of obesity, 2004;28, S2-S9.
5. Qian, Y., Nayga Jr, R. M., Thomsen, M. R., & Rouse, H. L. The effect of the fresh fruit and
vegetable program on childhood obesity. 2015.; Applied Economic Perspectives and Policy:38(2),
260-275.
6. Wen, Leana and Pugh, Catherine. State of health in Baltimore: White paper 2017. 2017.
7. Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., ... & Henderson,
P. N. Clinical practice guideline. rockville, MD: US department of health and human services. .
2008;Public Health Service:1196-9.
8. Barriuso L, Miqueleiz E, Albaladejo R, Villanueva R, Santos JM, Regidor E. Socioeconomic
position and childhood-adolescent weight status in rich countries: A systematic review, 1990-2013.
BMC Pediatr. 2015;15:129-015-0443-3.
9. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and
excess adiposity among overweight children and adolescents: The Bogalusa heart study. J Pediatr.
2007;150(1):12-17.e2.
10. Gerlach G, Herpertz S, Loeber S. Personality traits and obesity: A systematic review. Obes Rev.
2015;16(1):32-63.
11. Hopkins LC, Sattler M, Steeves EA, Jones-Smith JC, Gittelsohn J. Breakfast consumption
frequency and its relationships to overall diet quality, using healthy eating index 2010, and body
mass index among adolescents in a low-income urban setting. Ecol Food Nutr. 2017;56(4):297-311.
PAGE 12
12. Rueegg CS, Kriemler S, Zuercher SJ, et al. A partially supervised physical activity program for
adult and adolescent survivors of childhood cancer (SURfit): Study design of a randomized
controlled trial [NCT02730767. BMC Cancer. 2017;17(1):822-017-3801-8.
13. Falkner NH, Neumark-Sztainer D, Story M, Jeffery RW, Beuhring T, Resnick MD. Social,
educational, and psychological correlates of weight status in adolescents. Obes Res. 2001;9(1):32-
42.
14. Jin LZ, Rangan A, Mehlsen J, Andersen LB, Larsen SC, Heitmann BL. Association between use
of cannabis in adolescence and weight change into midlife. PLoS One. 2017;12(1):e0168897.
15. Cluss PA, Ewing L, King WC, Reis EC, Dodd JL, Penner B. Nutrition knowledge of low-income
parents of obese children. Transl Behav Med. 2013;3(2):218-225.
16. Fuemmeler BF, Lovelady CA, Zucker NL, Ostbye T. Parental obesity moderates the
relationship between childhood appetitive traits and weight. Obesity (Silver Spring).
2013;21(4):815-823.
17. Kramer RF, Coutinho AJ, Vaeth E, Christiansen K, Suratkar S, Gittelsohn J. Healthier home
food preparation methods and youth and caregiver psychosocial factors are associated with lower
BMI in african american youth. J Nutr. 2012;142(5):948-954.
18. Anderson YC, Wynter LE, Grant CC, et al. Physical activity is low in obese new zealand
children and adolescents. Sci Rep. 2017;7:41822.
19. Aldhoon-Hainerova I, Hainer V, Zamrazilova H. Impact of dietary intake, lifestyle and
biochemical factors on metabolic health in obese adolescents. Nutr Metab Cardiovasc Dis.
2017;27(8):703-710.
20. Dodson JL, Hsiao YC, Kasat-Shors M, et al. Formative research for a healthy diet intervention
among inner-city adolescents: The importance of family, school and neighborhood environment.
Ecol Food Nutr. 2009;48(1):39-58.
21. Keller A, Bucher Della Torre S. Sugar-sweetened beverages and obesity among children and
adolescents: A review of systematic literature reviews. Child Obes. 2015;11(4):338-346.
22. De Silva‐Sanigorski, A. M., & Economos, C. Evidence of Multi‐Setting approaches for obesity
prevention: Translation to best practice. . Preventing Childhood Obesity: Evidence Policy and
Practice. 2010:57-63.
PAGE 13
23. Gittelsohn J, Trude AC, Poirier L, et al. The impact of a multi-level multi-component
childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a
low-income urban area. Int J Environ Res Public Health. 2017;14(11):10.3390/ijerph14111371.
24. Hendriks AM, Jansen MW, Gubbels JS, De Vries NK, Paulussen T, Kremers SP. Proposing a
conceptual framework for integrated local public health policy, applied to childhood obesity--the
behavior change ball. Implement Sci. 2013;8:46-5908-8-46.
25. Gortmaker SL, Peterson K, Wiecha J, et al. Reducing obesity via a school-based
interdisciplinary intervention among youth: Planet health. Arch Pediatr Adolesc Med.
1999;153(4):409-418.
26. Wang Y, Cai L, Wu Y, et al. What childhood obesity prevention programmes work? A
systematic review and meta-analysis. Obes Rev. 2015;16(7):547-565.
27. Wiecha JL, El Ayadi AM, Fuemmeler BF, et al. Diffusion of an integrated health education
program in an urban school system: Planet health. J Pediatr Psychol. 2004;29(6):467-474.
28. Sallis, J. F., McKenzie, T. L., Conway, T. L., Elder, J. P., Prochaska, J. J., Brown, M.
Environmental interventions for eating and physical activity: A randomized controlled trial in
middle schools
. American journal of preventive medicine. 2003;24(3), 209-217.
29. Whitt-Glover, M. C., Taylor, W. C., Floyd, M. F., Yore, M. M., Yancey, A. K., & Matthews, C. E.
Disparities in physical activity and sedentary behaviors among US children and adolescents:
Prevalence, correlates, and intervention implications. . Journal of Public Health Policy,. 2009;30(1),
S309-S334.