Evaluating State Public Health Nutrition Programs

Marilyn Sitaker, MPH, EpidemiologistCardiovascular Disease, Diabetes, Nutrition and Physical Activity Section, Washington State Department of Health

Learning Objectives for this Lecture

 Identify sources of data for nutrition and physical activity surveillance used for state-level planning and monitoring.

Describe the strengths and weaknesses of existing data and data systems for state level practice 

Analyze the application and politics of the use of data at the state level for reports, policy development, and performance measures.

Apply these understandings to state level evaluation of the Washington State Plan for Nutrition and Physical Activity

Washington State Plan for Physical Activity and Nutrition

Purpose:

1.  Slow the increase in the proportion of adults who are obese

2.  Reduce rates of chronic disease

3.  Improve the quality of life

Overarching goals:

·       * Increase the proportion of adults and children who have diets that reflect the Dietary Guidelines for Americans.

·       * Increase the proportion of adults and children who meet the physical activity recommendations.

Objectives of the State Plan

Nutrition Objectives:

1. Increase access to health promoting foods

2. Reduce hunger and food insecurity

3. Increase the proportion of mothers who breastfeed their infants and toddlers

Physical activity Objectives:

1. Increase the number of people who have access to free or low cost recreational opportunities for physical activity

2. Increase the number of physical activity opportunities available to children

3. Increase the number of active community environments

Nutrition Sub-objectives: Increase access to health promoting foods

Increase the consumption of vegetables and fruits.

Assure that worksites provide healthful foods and beverages

Ensure that K-12 schools provide healthful foods and beverages

Reduce hunger and food insecurity

Provide adequate support for nutrition and food programs

Improve access to nutrition programs

Increase the proportion of mothers who breastfeed their infants and toddlers

Assure that health care settings, child care facilities, and worksite environments are breastfeeding-friendly.

Physical Activity Sub-objectives: Increase the # of people who have access to free or low cost recreational

opportunities for physical activity Adequate funding for state and local recreational sites and facilities. Model policies to increase access to public facilities for PA Increase the number of worksites with policies that facilitate opportunities

for PA Increase the # of physical activity opportunities available to children

School based curricula and policies for quality, daily physical education Policies to provide K-12 students with opportunities for PA outside of P.E.

Class Replace sedentary behaviors, such as watching television, with physical

activity Increase the # of active community environments in Washington State

Use urban planning approaches – zoning and land use. Change transportation policy to promote non-motorized transportation Enhance safety and perceived safety to improve walkability and bikeability

Structures, Policies, SystemsLocal, state, federal policies and laws to

regulate/support healthy actions

InstitutionsRules, regulations, policies &

informal structures

CommunitySocial Networks, Norms, Standards

InterpersonalFamily, peers, social networks,

associations

IndividualKnowledge, attitudes,

beliefs

Levels of Influence in the Social-Ecological Model

Focus of the Washington

State Plan for Nutrition and

Physical Activity

Environment

What do we mean by “Environment?”Physical

Safe walking paths, home

gardens, fresh produce in

local markets

Sociocultural

Value that schools place of physical

education; teachers serve as

role models

PoliciesActive transport given priority.

Zoning for walking or cycling; protecting

open spaces

EconomicMonetary incentives/ disincentives in form

of taxes, pricing policies & subsidies

• Legislation & Policy Development with organizations & agencies

• Pilot Programs (Vending, schools)

Development of local action plans, using strategies f rom the State Plan

Communication & outreach

Develop & implement policy recommendations by sectors

Activities Short-Term Outcomes

I ntermediate Outcomes

LOGI C MODEL: Washington State Plan for Physical Activity and Nutrition

Physical Activity & I mproved dietary behavior

Changes in the environment

Local CommunityHealthy CommunititesSTEPS Communitites

Prevention Block Grants

State- wide CoalitionsAction f or Healthy Kids,

Access to Healthy Foods, Food Policy

Council, WA PA Coalition, WA Coalition

for Healthy Aging

SystemsCTED, DOT, Parks & Rec

I nputs

DOH Staff , Time, Money

Communication & outreach

Partner with systems, state coalitions & local communities

Technical assistance & training,

Development of assessment tools & resource guides

Partnerships & Collaborations are Established

and Working

Partners are Knowledgeable About Env & Policy I ssues that I mpact

Physical Activity & Nutr. Behavior

I ncreased Media Coverage About Physical Activity

& Nutrition

Financial Support f or Physical Activity & Nutrition Eff orts

I ncreases

Partners I ncorporate

State Plan into their Own Work

Plans

CDC: funds & guidance Changes

in Policy

Long-Term

Outcomes

Decreased incidence of chronic disease

Decreased Obesity

Evaluation of the State Plan Statewide Assessment 

Level 1: Monitor progress on implementation of State Plan & meeting plan objectives

Level 2. Monitor environmental and policy efforts related to nutrition and physical activity

Level 3: Ongoing monitoring of long term objectives: nutrition & physical activity; obesity; and prevalence of chronic diseases

Evaluation of the State Plan Statewide Assessment 

Level 1: Monitor progress on implementation of State Plan & meeting plan objectives

1. Increase access to health promoting foods

2. Reduce hunger and food insecurity

3. Increase the percent of mothers who breastfeed their infants and toddlers

4. Increase the number of persons in communities who have access to free and low cost recreational opportunities for physical activity

5. Increase the number of physical activity opportunities specifically available to children

6. Increase the number of active community environments

Evaluation of the State Plan Statewide Assessment 

Level 2. Monitor environmental and policy efforts related to nutrition and physical activity School Health Policy Survey: School Health

Profiles, a CDC- sponsored survey

Worksite Policy Survey: DOH-sponsored survey

Community Poll: DOH-sponsored survey

Healthcare Quality: DOH-sponsored survey

Worksite Policy SurveySector:Worksite

Access to Healthy Foods Breastfeeding Free or Reducedcost opportunitiesfor physical activity

Increase ActiveCommunityEnvironments

DataCollectionTool:WorksiteSurvey

Has a written policy for healthy foods at meetings.

Has a place for employees to sit & eat meals

Has microwaves employees can use to cook their food

Has refrigerators for employees to store their food

Low-fat milk, fresh fruits & vegetables, water, 100% juice, and low fat snacks are available in cafeteria.

Low-fat milk, fresh fruits & vegetables, water, 100% juice, and low fat snacks are available in vending.

“Healthy food” labeling used in cafeteria

“Healthy food” labeling used in vending

Has a writtenbreastfeedingpolicy.Allows flexibleschedule with

timeTo pump orbreastfeed.Has a designated

breastfeeding room or area.

Breastfeeding room has electrical outlet, locking door, sink with soap & water, refrigerator to store milk.

Has a policy for employees to use paid time or flex time for exercise

Provides subsidy to fitness clubs or gyms

Has a policy to encourage employees to take stairs (in buildings with elevators present)

Has signs to promote stair use (in buildings with elevators present)

Has policies to encourage alternative transportation to work

Has policies toencouragealternativetransportation towork(walk/bike/publictransportation)

Low Fat Snacks* and Fruits/Veg by Worksite Food Source

0% 20% 40% 60% 80% 100%

cafeteria

snack bar/coffee stand

vending

free foodLow FatSnacks

FreshFruits orVegetables

* Pretzels, chex mix, granola bars

Worksite policies & practices to encourage non-motorized tranport

0% 20% 40% 60% 80% 100%

Policy: w alk& bike

Subsidize public transport

Secured bike storage at w ork

Show ers

Community Environments PollSector: Community

Access to healthy foods Free or reduced-cost opportunities for physical activity

Data Collection Tool:Community Poll

Healthier food choices are clearly labeled in the store, such that nutritional information, such as the fat and calorie content, can be evaluated. Whole grain foods available in store. 1% or non-fat milk and milk products available in store.Lean meats and fish available in store.Fresh fruits and vegetables available in store.Brightly-colored fresh fruits and vegetables, available in store.Affordable fresh fruits and vegetables are available in store.High-quality fresh fruits and vegetables are available in store.Healthy choices available on restaurant menus, such as main dish salads, low-fat or low-calorie optionsHealthier food choices on menus clearly labeled as "healthy". Menu substitutions to get healthier items are permissable.It is possible to get nutritional information, such as the fat and calorie content of menu items from information listed on the menu or posted in the restaurant.

Places available to engage in physical activity, including local schools, community recreational centers or gyms, parks, parks with playgrounds, and trails for walking and biking: (Is the destination there & what is the distance)Availability of places to walk or bike to in the communityHow long it would take to walk to the nearest grocery or supermarket; convenience store or small grocery store; school; restaurant;parks; playgrounds; trails;

Availability of Healthy, Affordable Foods in the Grocery Store

0% 20% 40% 60% 80% 100%

Healthy foods are clearly labelled

I can compare nutritional information

I can f ind w hole grain foods

I can f ind low fat dairy products

I can f ind lean meats and f ish

I can f ind fresh fruits, vegetables andsalad ingredients

I can f ind brightly colored fruits andvegetables

The cost of fresh fruits & vegetablesmakes it easy to include in my diet

The fresh fruits & vegetables I can f indare high quality

From the Washington 2004 Health

Profile Survey – Fact Sheet Series :

Nutrition:

Most schools provide access to food or beverages in addition to cafeteria foods: 91% of schools have vending machines or a school store, canteen, or snack bar where students can purchase snack foods or beverages. The foods listed in the table at the right are available from these “competitive food sources”:

The overall high availability of high-sugar drinks and foods and low availability of fruits and vegetables at schools is at odds with health messages to moderate intake of sugars and choose a variety of fruits and vegetables daily.

School Health Profile

Healthier options

Bottled water 96%

100% Fruit juice 86%

Salty, low-fat snacks including pretzels, baked chips

84%

Low-fat baked goods including cookies, crackers, cakes, pastries

64%

Fruits or vegetables 46%

Less healthy options

Soft drinks, sports drinks and non-100% fruit drinks

97%

Salty, fat snacks including regular potato chips

80%

Chocolate candy 72%

Other candy 75%

Evaluation of the State Plan Statewide Assessment 

Level 3: Ongoing monitoring of long term objectives: nutrition & physical activity; obesity; and prevalence of chronic diseases Washington Vital Records System (death

certificates)

Washington Behavioral Risk Factor Surveillance System

Data Sources: Death Certificate System

Annual information on all deaths that occur in Washington, and of Washington residents who die in other states;

Estimated to be 99% complete.

Cause of death determined by the attending physician or the coroner/ medical examiner.

Instruction manuals are provided to physicians, coroners, and medical examiners, as well as local health jurisdictions and others involved in completing and managing death certificates.

Causes of death are coded according to the International Classification of Disease, World Health Organization, Ninth Revision (ICD-9) for 1979-1998; Tenth revision (ICD-10) for 1999 and later.

Coronary Heart Disease Mortality Washington State Residents and United States, 1990-2002

0

100

200

300

400

1990

1991

1992

1993

1994

1995

1996

1997

1998

*

1999

2000

2001

2002

United States

Washington

Year 2010 Objective

Trends in Diabetes Deaths by Race & Ethnicity Washington 1990-2003

0

10

20

30

40

50

60

70

80

1990-1992

1991-1993

1992-1994

1993-1995

1994-1996

1995-1997

1996-1998

* 1999-2001

2000-2002

2001-2003

Ra

te p

er

10

0,0

00

NH Whites NH African Americans NH Amer Indian/AK NH Asian/NHoPI Hispanic

Data Sources: Washington Behavioral Risk Factor

Surveillance System (BRFSS) Telephone health survey of chronic diseases, injuries and

their risk factors, coordinated by the Center for Disease Control and Prevention (CDC), conducted annually in 50 states since 1986

Self-reported information collected from a random sample of adults living in households with telephones.

2003 data includes 18,000+ records to facilitate county level estimation; 400 interview conducted in Spanish.

BRFSS Topics Health status, including general, physical, and mental heath, as well as

activity lost because of health conditions. Access to health care, as measured by having health insurance, being

able to see a doctor because of cost, and time since last routine checkup. Awareness of selected medical conditions:  hypertension, diabetes, and

high cholesterol. Nutrition and weight control, including eating of fruits and vegetables

and experiencing hunger. Injury control, including use of seatbelts by respondents and children in

their household. Tobacco use and alcohol consumption. Social and demographic characteristics, including gender, age,

race/ethnicity, marital status, education attainment, employment, household income, weight and height.

For example the nutrition module asks how often certain foods are eaten: fruit juice, fruit, green salad & potatoes (other than french fries, fried potatoes or chips) and carrots.

A summary index measure is derived from these questions

Note: how often an item is eaten is not the same as number of servings

Fruits and Vegetables (BRFSS, 2003)These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home.

7.1 How often do you drink fruit juices such as orange, grapefruit, or tomato?

7.2 Not counting juice, how often do you eat fruit?

7.3 How often do you eat green salad?

7.4 How often do you eat potatoes not including French fries, fried potatoes, or potato chips?

7.5 How often do you eat carrots?

7.6 Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?

Eat Fruit and Vegetables 5 Times a Day Washington Adults

by Age Group, 2003

15 20 25 30 35

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 and over

Age

Gro

up

Percent

Eat Fruit and Vegetables 5 Times a Day Washington Adults by

Race and Ethnicity, 2003

5 10 15 20 25 30 35 40

White

Black

Asian/PacificIslander

AmIndian/Alaskan

Hispanic

Non Hispanic

Rac

eE

thni

cgr

oup

Percent

Eat Fruit and Vegetable 5 Times a Day

Among Washington Adults by Income, 2003

13151719212325272931

<$15,000 $15,000-$24,999

$25,000-$34,999

$35,000-$49,999

$50,000-$74,999

$75,000 ormore

Income Level

Per

cent

Eat Fruit and Vegetables 5 Times a Day Among Washington

Adults by Education, 2003

15

17

19

21

23

25

27

29

Less than highschool

High schoolgraduate/GED

Some post highschool

College graduate

Educational Level

Per

cent

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Obesity

Diabetes

Eat Fruits & Veg. < 5 Times a Day

Smoking

Insufficient Physical Activity

High Blood Pressure

High Blood Cholesterol

BRFSS, most recent year data available (2002)

BRFSS, most recent year data available (2001)

CVD Risk Factors Among Washington Adults, 2001 or 2002

Overweight and Obesity Prevalence, Age 18 and Older, Washington 1990-2004

0

10

20

30

40

50

60

70

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004Year

Per

cen

t

Obese

Overweight

9%

16%

36.%33%

Rates of Obesity and Diabetes Prevalence among Adults in Washington, 1993-2004

0

5

10

15

20

25

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Ag

e-a

dju

ste

d r

ate

pe

r 1

00

Obesity

Diabetes

Source: Washington Behavioral Risk Factor Survey

Data Sources: Washington Healthy Youth Survey

(HYS) Sponsored by OSPI, DOH, DSHS-DASA, and Office of

Community Development

Health pencil-and-paper survey combining questions from the CDC’s Youth Behavioral Risk Survey (YBRS) and the Monitoring the Future survey

Representative sample of schools within a school district

Grades 6, 8, 10 and 12 answered questions about safety and violence, physical activity and diet, alcohol, tobacco and other drug use, and related risk and protective factors. Administered in the Fall of 2002 & 2004.

Meeting recommended levels of vigorous daily activity: How many of the past 7 days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities?  Meeting recommended levels of moderate daily activity: How many of the past 7 days did you do physical activity for at least 30 minutes that did not make you sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping floors?  Strength Training: How many of the past 7 days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?

Questions about Physical Activity on the HYS

Number of (Non-Diet) Sodas Yesterday

19.9

32.1

0

10

20

30

40

50

girls boys

46.1

28.1

13.5

6.8 5.5

0

10

20

30

40

50

0 1 2 3 4+

Distribution, Grade 10

16.2

27 25.827.3

0

10

20

30

40

50

6th 8th 10th 12th

2+ by Grade* 2+, Grade 10 by Sex*

* P < 0.05

0

10

20

30

40

50

Grade 8 Grade 10 Grade 12

overweight risk for overweight neither

Per

cent

Overweight and 2+ Sodas Yesterday

* P < 0.05

*

*

* *

0

10

20

30

40

* P < 0.05

2 or more (non-diet) sodas yesterday and other nutrition-related questions, grade 10 example

**

*

5 <5 yes no yes no yes no daily times usually food insecure inappropriate fruit & veggies family dinner dieting (girls)

Per

cent

Pregnancy Risk Assessment Monitoring System Joint research project of the Washington DOH & CDC since 1996

Mail/phone survey of ~ 2,000 new mothers, randomly sampled (by race/ethnicity) from birth certificate records, at 2-6 months after delivery.

Provides data for the period before, during and shortly after their pregnancy

Topics include: prenatal care received, health behaviors during pregnancy, & barriers to receiving prenatal care

Also: consumer ideas about pregnancy and early infant care

And, finally: intendedness of pregnancy, use of alcohol and tobacco, baby's sleeping position, percent of women breastfeeding, social support, and battering during pregnancy.

Breastfeeding in Washington, 1998-2002, PRAMS

0 20 40 60 80 100

2002

2001

2000

1999

PercentAt 8 WeeksInitiation rates