American Journal of Preventive Medicine

Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap

Y. Claire Wang, C. Tracy Orleans, Steven L. Gortmaker — 2012-05-01

Background: The federal government has set measurable goals for reducing childhood obesity to 5% by 2010 (Healthy People 2010), and 10% lower than 2005–2008 levels by 2020 (Healthy People 2020). However, population-level estimates of the changes in daily energy balance needed to reach these goals are lacking. Purpose: To estimate needed per capita reductions in youths' daily “energy gap” (calories consumed over calories expended) to achieve Healthy People goals by 2020. Methods: Analyses were conducted in 2010 to fit multivariate models using National Health and Nutrition Examination Surveys 1971–2008 (N=46,164) to extrapolate past trends in obesity prevalence, weight, and BMI among youth aged 2–19 years. Differences in average daily energy requirements between the extrapolated 2020 levels and Healthy People scenarios were estimated. Results: During 1971–2008, mean BMI and weight among U.S. youth increased by 0.55 kg/m2 and by 1.54 kg per decade, respectively. Extrapolating from these trends to 2020, the average weight among youth in 2020 would increase by ∼1.8 kg from 2007–2008 levels. Averting this increase will require an average reduction of 41 kcal/day in youth's daily energy gap. An additional reduction of 120 kcal/day and 23 kcal/day would be needed to reach Healthy People 2010 and Healthy People 2020 goals, respectively. Larger reductions are needed among adolescents and racial/ethnic minority youth. Conclusions: Aggressive efforts are needed to reverse the positive energy imbalance underlying the childhood obesity epidemic. The energy-gap metric provides a useful tool for goal setting, intervention planning, and charting progress.

Physical Activity, Sedentary Behavior, and Adiposity in English Children

2012-05-01

Background: The importance of variation in total volume of physical activity or moderate- to vigorous-intensity physical activity (MVPA) to development of body fatness in childhood is unclear, and it is unclear if physical activity has a greater influence on adiposity in boys than girls. Purpose: To assess relationships between 2-year changes in objectively measured physical activity, sedentary behavior, and adiposity in English children. Methods: Prospective cohort study, set in Northeast England, of a socioeconomically representative sample of 403 children. Measures were change in accelerometer-determined physical activity and sedentary behavior from age 7 to 9 years (data collected 2006/2007 and 2008/2009; analyzed in 2010) and concurrent change in adiposity (fat mass index derived from bioelectric impedance) and change in BMI Z-score. Results: Decline in MVPA was associated with a greater increase in fat mass index in boys but not girls. Declining MVPA was associated with increased BMI Z-score in boys but not girls. Increased sedentary behavior was not associated with increased BMI Z-score in either gender. Conclusions: Avoiding mid–late childhood reductions in MVPA may reduce excessive fat gain, although such strategies may have greater impact on boys than girls.

Physical Education Policy Compliance and Children's Physical Fitness

2012-05-01

Background: Physical education policies have received increased attention as a means for improving physical activity levels, enhancing physical fitness, and contributing to childhood obesity prevention. Although compliance at the school and district levels is likely to be critical for the success of physical education policies, few published studies have focused on this issue. Purpose: This study investigated whether school district–level compliance with California physical education policies was associated with physical fitness among 5th-grade public-school students in California. Methods: Cross-sectional data from FITNESSGRAM® 2004–2006, district-level compliance with state physical education requirements for 2004–2006, school- and district-level information, and 2000 U.S. Census data were combined to examine the association between district-level compliance with physical education policies and children's fitness levels. The analysis was completed in 2010. Results: Of the 55 districts with compliance data, 28 (50%) were in compliance with state physical education mandates; these districts represented 21% (216) of schools and 18% (n=16,571) of students in the overall study sample. Controlling for other student-, school-, and district-level characteristics, students in policy-compliant districts were more likely than students in noncompliant districts to meet or exceed physical fitness standards (AOR=1.29, 95% CI=1.03, 1.61). Conclusions: Policy mandates for physical education in schools may contribute to improvements in children's fitness levels, but their success is likely to depend on mechanisms to ensure compliance.

Cardiorespiratory Fitness, Alcohol, and Mortality in Men: The Cooper Center Longitudinal Study

Kerem Shuval, Carolyn E. Barlow, Karen G. Chartier, Kelley Pettee Gabriel — 2012-05-01

Background: Studies have found that higher levels of cardiorespiratory fitness and light to moderate alcohol intake reduce the risk for premature death. Scant evidence, however, exists assessing the joint effects of both measures on all-cause and cardiovascular disease (CVD) mortality. Purpose: This study aims to examine the independent and joint effects of alcohol consumption and cardiorespiratory fitness on all-cause and cardiovascular-related mortality in a large cohort of men. Methods: This prospective study included 29,402 men who came to the Cooper Clinic (Dallas, TX) for a preventive medicine visit from 1973 to 2006. Data were analyzed in 2011. The primary exposure variables were tertiles of cardiorespiratory fitness and four categories of alcohol consumption, and the outcomes were all-cause and CVD mortality. Cox proportional hazards regression was used to model the association between alcohol intake, cardiorespiratory fitness, and all-cause and CVD mortality, controlling for potential confounders. Results: A total of 1830 (all-cause) and 523 (CVD) deaths occurred in men over an average follow-up period of 17.4 years (SD=9.1). A linear relationship was observed (p<0.001) between increased fitness and reduced all-cause and CVD mortality. Specifically, moderate and high levels of fitness reduced the risk for all-cause mortality (HR=0.67, 95% CI=0.60, 0.74, and HR=0.57, 95% CI=0.49, 0.67, respectively) and CVD mortality in comparison to the low-fitness reference group (HR=0.70, 95% CI=0.57, 0.85; HR=0.54, 95% CI=0.40, 0.75, respectively), while controlling for alcohol intake and other covariates. A significant curvilinear relationship was found (p=0.01) between alcohol intake and all-cause mortality (but not CVD mortality), while controlling for fitness and other covariates. In a categoric examination of alcohol intake and mortality, adjusting for fitness and other confounders, there was no statistically significant effect of light drinking compared to heavy drinking on all-cause mortality or CVD mortality. An examination of the joint effects of fitness and alcohol on all-cause mortality showed that moderate and high fitness levels were protective against mortality irrespective of alcohol consumption levels. Few significant combined effects for CVD mortality reduction were found. Conclusions: Alcohol consumption did not significantly modify the association between fitness and mortality in this large cohort of men.

Safe in the City: Effective Prevention Interventions for Human Immunodeficiency Virus and Sexually Transmitted Infections

2012-05-01

Background: The public health literature documents the efficacy–effectiveness gap between research and practice resulting from the research priority of demonstrating efficacy at the expense of testing for effectiveness. Purpose: The Safe in the City video-based HIV/sexually transmitted infection (STI) prevention intervention designed for sexually transmitted disease (STD) clinic waiting rooms is presented as a case study to demonstrate the application of a new framework to bridge efficacy and effectiveness. The goal of the study is to determine the extent to which clinics are implementing the intervention. Methods: As part of the case study, data were collected from a convenience sample of 81 publicly funded STD clinics during program implementation to determine whether clinics were showing the video. A baseline telephone survey was administered to clinic directors from November to December 2008, and a follow-up was conducted from March to May 2009. Data analysis was completed in 2009. Results: At baseline, 41% of STD clinics were showing Safe in the City, which increased to 58% at follow-up. None reported previous implementation of behavioral interventions delivered in waiting rooms. Almost one fourth of clinics adapted the intervention by showing the video on laptop computers in examination rooms or in other venues with different audiences. Conclusions: The Safe in the City intervention was implemented by the majority of STD clinics and adapted for implementation. The framework for HIV/STI prevention intervention illustrates how measures of effectiveness were increased in the development, evaluation, dissemination, implementation and sustainability phases of research and program.

Health Indicators for Military, Veteran, and Civilian Women

2012-05-01

Background: Women who have served in the military are a rapidly growing population. No previous studies have compared directly their health status to that of civilians. Purpose: To provide estimates of several leading U.S. health indicators by military service status among women. Methods: Data were obtained from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. Health outcomes were compared by military status using multivariable logistic regression among the female participants (274,399 civilians, 4221 veterans, 661 active duty, and 995 National Guard or Reserves [NG/R]). Data were analyzed in August 2011. Results: Veterans reported poorer general health and greater incidence of health risk behaviors, mental health conditions, and chronic health conditions than civilian women. Active duty women reported better access to health care, better physical health, less engagement in health risk behaviors, and greater likelihood of having had a recent Pap than civilian women. Women from the NG/R were comparable to civilians across most health domains, although they had a greater likelihood of being overweight or obese and reporting a depressive and anxiety disorder. Conclusions: Compared with civilian women, NG/R women rated their health and access to health care similarly and active duty women rated theirs better on several domains, but veterans consistently reported poorer health.

Successful Weight Loss Among Obese U.S. Adults

Jacinda M. Nicklas, Karen W. Huskey, Roger B. Davis, Christina C. Wee — 2012-05-01

Background: Little is known about weight control strategies associated with successful weight loss among obese U.S. adults in the general population. Purpose: To identify strategies associated with losing at least 5% and 10% of body weight. Methods: Multivariable analysis of data from obese adult (BMI ≥30) participants in the 2001–2006 NHANES to identify strategies associated with losing ≥5% and ≥10% of body weight (conducted in 2009–2011). Results: Of 4021 obese adults, 2523 (63%) reported trying to lose weight in the previous year. Among those attempting weight loss, 1026 (40%) lost ≥5% and 510 (20%) lost ≥10% weight. After adjustment for potential confounders, strategies associated with losing ≥5% weight included eating less fat (OR=1.41, 95% CI=1.14, 1.75); exercising more (OR=1.29, 95% CI=1.05, 1.60); and using prescription weight loss medications (OR=1.77, 95% CI=1.00, 3.13). Eating less fat (OR=1.37, 95% CI=1.04, 1.79); exercising more (OR=1.36, 95% CI=1.12, 1.65); and using prescription weight loss medications (OR=2.05, 95% CI=1.09, 3.86) were also associated with losing ≥10% weight, as was joining commercial weight loss programs (OR=1.72, 95% CI=1.00, 2.96). Adults eating diet products were less likely to achieve 10% weight loss (OR=0.48, 95% CI=0.31, 0.72). Liquid diets, nonprescription diet pills, and popular diets had no association with successful weight loss. Conclusions: A substantial proportion of obese U.S. adults who attempted to lose weight reported weight loss, at least in the short term. Obese adults were more likely to report achieving meaningful weight loss if they ate less fat, exercised more, used prescription weight loss medications, or participated in commercial weight loss programs.

Physical Activity and Physical Fitness: Standardizing Assessment with the PhenX Toolkit

2012-05-01

Abstract: The focus of the PhenX (Phenotypes and eXposures) Toolkit is to provide researchers whose expertise lies outside a particular area with key measures identified by experts for uniform use in large-scale genetic studies and other extensive epidemiologic efforts going forward. The current paper specifically addresses the PhenX Toolkit research domain of physical activity and physical fitness (PA/PF), which are often associated with health outcomes. A Working Group (WG) of content experts completed a 6-month consensus process in which they identified a set of 14 high-priority, low-burden, and scientifically supported measures. During this process, the WG considered self-reported and objective measures that included the latest technology (e.g., accelerometers, pedometers, and heart-rate monitors). They also sought the input of measurement experts and other members of the research community during their deliberations. A majority of the measures include protocols for children (or adolescents), adults, and older adults or are applicable to all ages. Measures from the PA/PF domain and 20 other domains are publicly available and found at the PhenX Toolkit website, www.phenxtoolkit.org. The use of common measures and protocols across large studies enhances the capacity to combine or compare data across studies, benefiting both PA/PF experts and non-experts. Use of these common measures by the research community should increase statistical power and enhance the ability to answer scientific questions that previously might have gone unanswered.

Active Transport, Physical Activity, and Body Weight in Adults: A Systematic Review

2012-05-01

Context: Physical activity has various health benefits. Active transport can contribute to total physical activity and thus affect body weight because of increased energy expenditure. This review summarizes published evidence on associations of active transport, general physical activity, and body weight in adults. Evidence acquisition: A systematic review of the literature was conducted in October 2010 using eight databases. A total of 14,216 references were screened; full texts were retrieved for 95 articles. Forty-six articles (36 unique studies) were included: 20 (17) from Europe; 18 (13) from North America, Australia, and New Zealand; and eight (six) from other countries. Analyses of the retrieved papers were carried out between November 2010 and March 2011. Evidence synthesis: Of 15 studies assessing active transport and physical activity, five found associations in the expected direction (more active transport associated with more physical activity) for all or most variables studied, nine found some associations, and one reported no associations. Of 30 studies assessing active transport and body weight, 13 reported associations in the expected direction (more active transport associated with lower body weight) for all or most variables studied, 12 found some associations, two presented some associations in the expected and some in the opposite direction, and three reported no associations. Conclusions: There is limited evidence that active transport is associated with more physical activity as well as lower body weight in adults. However, study heterogeneity, predominantly cross-sectional designs, and crude measures for active transport and physical activity impede quantitative conclusions.

Retail Grocery Store Marketing Strategies and Obesity: An Integrative Review

Karen Glanz, Michael D.M. Bader, Shally Iyer — 2012-05-01

Context: In-store food marketing can influence food-purchasing behaviors and warrants increased attention given the dramatic rise in obesity. Descriptive and experimental studies of key marketing components have been conducted by consumer scientists, marketing researchers, and public health experts. This review synthesizes research and publications from industry and academic sources and provides direction for developing and evaluating promising interventions. Evidence acquisition: Literature sources for the review were English-language articles published from 1995 to 2010, identified from multidisciplinary search indexes, backward searches of cited articles, review articles, industry reports, and online sources. Only articles that focused on physical grocery stores and food products were included. Data collection occurred in 2010 and 2011. Evidence synthesis: Articles were classified in the categories of product, price, placement, and promotion and divided into controlled laboratory experiments, observation, and field experiments; 125 primary peer-reviewed articles met the inclusion criteria. Narrative synthesis methods were used. Key findings were synthesized by category of focus and study design. Evidence synthesis was completed in 2011. Conclusions: Findings suggest several strategies for in-store marketing to promote healthful eating by increasing availability, affordability, prominence, and promotion of healthful foods and/or restricting or de-marketing unhealthy foods. Key results of research in controlled laboratory studies should be adapted and tested in real-world in-store settings. Industry methods for assessing consumer behavior, such as electronic sales data and individually linked sales information from loyalty card holders, can help public health researchers increase the scientific rigor of field studies.

The Role of the Geographic Information Systems Infrastructure in Childhood Obesity Prevention: Perspective from the Robert Wood Johnson Foundation

Celeste Marie Torio — 2012-05-01

Childhood obesity is a serious public health epidemic. Childhood obesity rates have soared in just 4 decades, nearly tripling in children aged 2–5 years and 12–19 years, while quadrupling in children and adolescents aged 6–11 years. Recent estimates from the National Health and Nutrition Examination Survey report that 17% of children and adolescents aged 2–19 years are overweight.

Thinking About Place, Spatial Behavior, and Spatial Processes in Childhood Obesity

Stephen A. Matthews — 2012-05-01

There is no single solution to the childhood obesity epidemic, but there is a need for transdisciplinary collaboration and approaches that consider the potential mechanisms that promote or reduce obesity at all levels of enquiry, from cells to society. In this theme issue of the American Journal of Preventive Medicine, we focus on place (obesogenic and leptogenic environments), specifically the use of GIS, related technologies, and spatial analytical methods in the study of childhood obesity.

Obesogenic Environments in Youth: Concepts and Methods from a Longitudinal National Sample

Janne Boone-Heinonen, Penny Gordon-Larsen — 2012-05-01

Abstract: To effectively prevent and reduce childhood obesity through healthy community design, it is essential to understand which neighborhood environment features influence weight gain in various age groups. However, most neighborhood environment research is cross-sectional, focuses on adults, and is often carried out in small, nongeneralizable geographic areas. Thus, there is a great need for longitudinal neighborhood environment research in diverse populations across the life cycle. This paper describes (1) insights and challenges of longitudinal neighborhood environment research and (2) advancements and remaining gaps in measurement and study design that examine individuals and neighborhoods within the context of the broader community. Literature-based research and findings from the Obesity and Neighborhood Environment Database (ONEdata), a unique longitudinal GIS that is spatially and temporally linked to data in the National Longitudinal Study of Adolescent Health (N=20,745), provide examples of current limitations in this area of research. Findings suggest a need for longitudinal methodologic advancements to better control for dynamic sources of bias, investigate and capture appropriate temporal frameworks, and address complex residential location processes within families. Development of improved neighborhood environment measures that capture relevant geographic areas within complex communities and investigation of differences across urbanicity and sociodemographic composition are needed. Further longitudinal research is needed to identify, refine, and evaluate national and local policies to most effectively reduce childhood obesity.

Objective Assessment of Obesogenic Environments in Youth: Geographic Information System Methods and Spatial Findings from the Neighborhood Impact on Kids Study

2012-05-01

Background: GIS-based walkability measures designed to explain active travel fail to capture “playability” and proximity to healthy food. These constructs should be considered when measuring potential child obesogenic environments. Purpose: The aim of this study was to describe the development of GIS-based multicomponent physical activity and nutrition environment indicators of child obesogenic environments in the San Diego and Seattle regions. Methods: Block group–level walkability (street connectivity, residential density, land-use mix, and retail floor area ratio) measures were constructed in each region. Multiple sources were used to enumerate parks (∼900–1600 per region) and food establishments (∼10,000 per region). Physical activity environments were evaluated on the basis of walkability and presence and quality of parks. Nutrition environments were evaluated based on presence and density of fast-food restaurants and distance to supermarkets. Four neighborhood types were defined using high/low cut points for physical activity and nutrition environments defined through an iterative process dependent on regional counts of fast-food outlets and overall distance to parks and grocery stores from census block groups where youth live. Results: To identify sufficient numbers of children aged 6–11 years, high physical activity environment block groups had at least one high-quality park within 0.25 miles and were above median walkability, whereas low physical activity environment groups had no parks and were below median walkability. High nutrition environment block groups had a supermarket within 0.5 miles, and fewer than 16 (Seattle) and 31 (San Diego) fast-food restaurants within 0.5 miles. Low nutrition environments had either no supermarket, or a supermarket and more than 16 (Seattle) and 31 (San Diego) fast-food restaurants within 0.5 miles. Income, educational attainment, and ethnicity varied across physical activity and nutrition environments. Conclusions: These approaches to defining neighborhood environments can be used to study physical activity, nutrition, and obesity outcomes. Findings presented in a companion paper validate these GIS methods for measuring obesogenic environments.

Obesogenic Neighborhood Environments, Child and Parent Obesity: The Neighborhood Impact on Kids Study

2012-05-01

Background: Identifying neighborhood environment attributes related to childhood obesity can inform environmental changes for obesity prevention. Purpose: To evaluate child and parent weight status across neighborhoods in King County (Seattle metropolitan area) and San Diego County differing in GIS-defined physical activity environment (PAE) and nutrition environment (NE) characteristics. Methods: Neighborhoods were selected to represent high (favorable) versus low (unfavorable) on the two measures, forming four neighborhood types (low on both measures, low PAE/high NE, high PAE/low NE, and high on both measures). Weight and height of children aged 6–11 years and one parent (n=730) from selected neighborhoods were assessed in 2007–2009. Differences in child and parent overweight and obesity by neighborhood type were examined, adjusting for neighborhood-, family-, and individual-level demographics. Results: Children from neighborhoods high on both environment measures were less likely to be obese (7.7% vs 15.9%, OR=0.44, p=0.02) and marginally less likely to be overweight (23.7% vs 31.7%, OR=0.67, p=0.08) than children from neighborhoods low on both measures. In models adjusted for parent weight status and demographic factors, neighborhood environment type remained related to child obesity (high vs low on both measures, OR=0.41, p<0.03). Parents in neighborhoods high on both measures (versus low on both) were marginally less likely to be obese (20.1% vs 27.7%, OR=0.66, p=0.08), although parent overweight did not differ by neighborhood environment. The lower odds of parent obesity in neighborhoods with environments supportive of physical activity and healthy eating remained in models adjusted for demographics (high vs low on the environment measures, OR=0.57, p=0.053). Conclusions: Findings support the proposed GIS-based definitions of obesogenic neighborhoods for children and parents that consider both physical activity and nutrition environment features.

Patterns of Obesogenic Neighborhood Features and Adolescent Weight: A Comparison of Statistical Approaches

2012-05-01

Background: Few studies have addressed the potential influence of neighborhood characteristics on adolescent obesity risk, and findings have been inconsistent. Purpose: Identify patterns among neighborhood food, physical activity, street/transportation, and socioeconomic characteristics and examine their associations with adolescent weight status using three statistical approaches. Methods: Anthropometric measures were taken on 2682 adolescents (53% female, mean age=14.5 years) from 20 Minneapolis/St. Paul MN schools in 2009–2010. Neighborhood environmental variables were measured using GIS data and by survey. Gender-stratified regressions related to BMI z-scores and obesity to (1) separate neighborhood variables; (2) composites formed using factor analysis; and (3) clusters identified using spatial latent class analysis in 2012. Results: Regressions on separate neighborhood variables found a low percentage of parks/recreation, and low perceived safety were associated with higher BMI z-scores in boys and girls. Factor analysis found five factors: away-from-home food and recreation accessibility, community disadvantage, green space, retail/transit density, and supermarket accessibility. The first two factors were associated with BMI z-score in girls but not in boys. Spatial latent class analysis identified six clusters with complex combinations of both positive and negative environmental influences. In boys, the cluster with highest obesity (29.8%) included low SES, parks/recreation, and safety; high restaurant and convenience store density; and nearby access to gyms, supermarkets, and many transit stops. Conclusions: The mix of neighborhood-level barriers and facilitators of weight-related health behaviors leads to difficulties disentangling their associations with adolescent obesity; however, statistical approaches including factor and latent class analysis may provide useful means for addressing this complexity.

Fast Food and Obesity: A Spatial Analysis in a Large United Kingdom Population of Children Aged 13–15

Lorna K. Fraser, Graham P. Clarke, Janet E. Cade, Kimberly L. Edwards — 2012-05-01

Background: The childhood obesity epidemic is a current public health priority in many countries, and the consumption of fast food has been associated with obesity. Purpose: This study aims to assess the relationship between fast-food consumption and obesity as well as the relationship between fast-food outlet access and consumption in a cohort of United Kingdom teenagers. Methods: A weighted accessibility score of the number of fast-food outlets within a 1-km network buffer of the participant's residence at age 13 years was calculated. Geographically weighted regression was used to assess the relationships between fast-food consumption at age 13 years and weight status at ages 13 and 15 years, and separately between fast-food accessibility and consumption. Data were collected from 2004 to 2008. Results: The consumption of fast food was associated with a higher BMI SD score (β=0.08, 95% CI=0.03, 0.14); higher body fat percentage (β=2.06, 95% CI=1.33, 2.79); and increased odds of being obese (OR=1.23, 95% CI=1.02, 1.49). All these relationships were stationary and did not vary over space in the study area. The relationship between the accessibility of outlets and consumption did vary over space, with some areas (more rural areas) showing that increased accessibility was associated with consumption, whereas in some urban areas increased accessibility was associated with lack of consumption. Conclusions: There is continued need for nutritional education regarding fast food, but public health interventions that place restrictions on the location of fast-food outlets may not uniformly decrease consumption.

Spatial Classification of Youth Physical Activity Patterns

2012-05-01

Background: Physical activity is an essential element in reducing the prevalence of obesity, but much is unknown about the intensity and location of physical activity among youth—this is important because adolescent health behaviors are predictive of behaviors in adults. Purpose: This study aims to identify the locations where youth moderate-to-vigorous physical activity (MVPA) occurs, and to examine how MVPA varies according to urbanicity (urban, suburban, rural). Methods: Participants included adolescent students (N=380, aged 12–16 years) from Halifax, Nova Scotia. Locations of MVPA were measured using accelerometers and GPS data loggers for up to 7 days. Specialized software was developed to integrate and process the data. Frequencies of MVPA by location were determined, and differences in MVPA were assessed for association with urbanicity. Results: Active commuting accounted for the largest proportion of time in MVPA among urban and suburban students. Rural students achieved most MVPA at school. Other residential locations, shopping centers, and green spaces accounted for a majority of the remaining MVPA. Minutes in MVPA varied significantly overall (196.6±163.8, 84.9±103.2, 81.7±98.2); at school (45.7±45.2, 18.6±28.0, 29.8±39.7); while commuting (110.3±107.1, 31.5±55.2, 19.5±39.7); and at other activity locations (19.7±27.1, 14.8±26.8, 12.0±22.1) and by urbanicity. Conclusions: Findings reveal that the journeys between locations are as important as home and school settings in contributing to greater MVPA in adolescent youth. The relative importance of context as a contributor to MVPA varies with urbanicity. Combining actimetry and GPS data provides a precise link between physical activity measurements and contexts of the built environment.

GIS and Public Health

Lawrence D. Frank — 2012-05-01

GIS and Public Health serves as both a comprehensive textbook on spatial analysis within a public health context and as a resource for those learning independently about what geographic information systems (GIS) is and how to apply it to a variety of health-related phenomena. This is an extremely dynamic and timely topic. Recent technologic advances and the resulting explosion in computing power have created the ability to collect, distribute, and convey spatial data in ways never before thought possible. An entirely new subfield of Geographic Information Science has emerged, which now serves as an analytical bridge between health and a myriad of other disciplines including urban planning, geography, transportation, political science, landscape architecture, ecology, and more. Resolution is now sufficiently high to capture the level of detail required to remotely evaluate most of the planet's surface. It is now possible through Google Earth to zoom in and out of most regions on the planet and nearly simulate actually being in another location. Sidewalk inventories for entire regions are now being constructed through satellite imagery; parcel-level land-use data are now collected in a sufficient detail to support the creation of common walkability measures predictive of physical activity across nations and continents; Google street view is now sufficiently detailed to support pedestrian environment audits without traveling to remote study locations; and a proximity to destination based “WalkScore” has now been calculated for nearly every address within the U.S. and many other nations.

Maphead: Charting the Wide, Weird World of Geography Wonks

Stephen A. Matthews — 2012-05-01

When author Ken Jennings of Jeopardy! fame says about his book that it's not necessarily about maps, rather “… it's a book about people who like maps,” you start to understand his point that the world is composed of those who like maps and those who don't. It's that simple. Here are some extracts from his book: Today, we're starting to see the effects on society as the first generation of acutely “over-parented” children reach adulthood. We know that their sedentary lifestyle has led to spikes in obesity and other health problems. We know they're technology addicts, spending every free waking hour—9 hours a day on average—staring at little glowing screens . . . . this generation's collective geo-awareness is in just as much jeopardy as its emotional independence or its body mass index. Today's stuck-inside kids feel little connection to nature and landscape. Most measures of outdoor activity—camping, fishing, hiking, visits to national parks and forests—are steadily declining by about 1% per year. The “boomers” are still going outside … but not their kids and grandkids. In 1966, British geographers coined the phrase “graphicacy” to refer to the human capability to understand charts and diagrams and symbols—the visual equivalent of literacy and numeracy. In essence, our schools are shortchanging students in spatial thinking. Teaching maps helps kids sharpen … visual skills, which are increasingly important today. Reading maps, our eyes are free to wander, spatially, the way they do when we study new surroundings in life. But we tend to “outsource” our spatial thinking to technology (as an example, the GPS navigation that causes drivers to head off cliffs or onto railroad tracks). Reckoning with our environment isn't a single skill; it's a whole web of spatial senses and abilities, many so fundamental that we can't afford to lose them to machines.

Recommendation from the Community Preventive Services Task Force for Use of Collaborative Care for the Management of Depressive Disorders

Community Preventive Services Task Force — 2012-05-01

Summary: The Community Preventive Services Task Force recommends collaborative care for management of depressive disorders, based on strong evidence of effectiveness in improving depression symptoms, adherence to treatment, response to treatment, and remission and recovery from depression.

Collaborative Care to Improve the Management of Depressive Disorders: A Community Guide Systematic Review and Meta-Analysis

2012-05-01

Context: To improve the quality of depression management, collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system–level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management. Evidence acquisition: A team of subject matter experts in mental health, representing various agencies and institutions, conceptualized and conducted a systematic review and meta-analysis on collaborative care for improving the management of depressive disorders. This team worked under the guidance of the Community Preventive Services Task Force, a nonfederal, independent, volunteer body of public health and prevention experts. Community Guide systematic review methods were used to identify, evaluate, and analyze available evidence. Evidence synthesis: An earlier systematic review with 37 RCTs of collaborative care studies published through 2004 found evidence of effectiveness of these models in improving depression outcomes. An additional 32 studies of collaborative care models conducted between 2004 and 2009 were found for this current review and analyzed. The results from the meta-analyses suggest robust evidence of effectiveness of collaborative care in improving depression symptoms (standardized mean difference [SMD]=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (SMD=0.12); and satisfaction with care (SMD=0.39) for patients diagnosed with depression (all effect estimates were significant). Conclusions: Collaborative care models are effective in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations. Collaborative care interventions provide a supportive network of professionals and peers for patients with depression, especially at the primary care level.

Economics of Collaborative Care for Management of Depressive Disorders: A Community Guide Systematic Review

2012-05-01

Context: Major depressive disorders are frequently underdiagnosed and undertreated. Collaborative Care models developed from the Chronic Care Model during the past 20 years have improved the quality of depression management in the community, raising intervention cost incrementally above usual care. This paper assesses the economic efficiency of collaborative care for management of depressive disorders by comparing its economic costs and economic benefits to usual care, as informed by a systematic review of the literature. Evidence acquisition: The economic review of collaborative care for management of depressive disorders was conducted in tandem with a review of effectiveness, under the guidance of the Community Preventive Services Task Force, a nonfederal, independent group of public health leaders and experts. Economic review methods developed by the Guide to Community Preventive Services were used by two economists to screen, abstract, adjust, and summarize the economic evidence of collaborative care from societal and other perspectives. An earlier economic review that included eight RCTs was included as part of the evidence. The present economic review expanded the evidence with results from studies published from 1980 to 2009 and included both RCTs and other study designs. Evidence synthesis: In addition to the eight RCTs included in the earlier review, 22 more studies of collaborative care that provided estimates for economic outcomes were identified, 20 of which were evaluations of actual interventions and two of which were based on models. Of seven studies that measured only economic benefits of collaborative care in terms of averted healthcare or productivity loss, four found positive economic benefits due to intervention and three found minimal or no incremental benefit. Of five studies that measured both benefits and costs, three found lower collaborative care cost because of reduced healthcare utilization or enhanced productivity, and one found the same for a subpopulation of the intervention group. One study found that willingness to pay for collaborative care exceeded program costs. Among six cost–utility studies, five found collaborative care was cost effective. In two modeled studies, one showed cost effectiveness based on comparison of $/disability-adjusted life-year to annual per capita income; the other demonstrated cost effectiveness based on the standard threshold of $50,000/quality-adjusted life year, unadjusted for inflation. Finally, six of eight studies in the earlier review reported that interventions were cost effective on the basis of the standard threshold. Conclusions: The evidence indicates that collaborative care for management of depressive disorders provides good economic value.

Collaborative Depression Care Models: From Development to Dissemination

Wayne Katon — 2012-05-01

In 1978 the first multi-site mental health epidemiologic study in the U.S. reported that more than 50% of community respondents with depressive disorders were treated exclusively within the primary care system. As a result, primary care was labeled the “de facto mental health system” for Americans with the more prevalent but less severe mental health disorders. Subsequent research over the next decade found that only 25% to 50% of patients with depressive disorders were accurately diagnosed by primary care physicians. Moreover, among those accurately diagnosed only ∼50% received minimally adequate pharmacologic treatment, and less than 10% received a minimally adequate number of psychotherapy visits.

Systemic Organizational Change for the Collaborative Care Approach to Managing Depressive Disorders

Michael T. Compton — 2012-05-01

The U.S. Preventive Services Task Force recommends screening for depression in adults and adolescents in outpatient primary care settings when adequate systems are in place for efficient diagnosis, treatment, and follow-up of depressive disorders. The Prevention Practice Committee of the American College of Preventive Medicine subsequently suggested that all primary care settings should have such systems in place, given the prevalence and associated morbidity of depressive disorders. In addition to facilitating routine screening and establishing the diagnosis, the collaborative care model, discussed in articles in this issue of the American Journal of Preventive Medicine, is designed to increase primary care providers' use of evidence-based protocols in managing depressive disorders and to improve clinical and community support for patients' active engagement in shared decision making and self-management. (Of note, I use the term patient herein for clarity and concision, although modern conceptions of recovery, which emphasize shared decision making and empowerment, rightly prefer terms like consumer, mental health service user, or client.)

Clinical and Community Prevention and Treatment Service for Depression: A Whole Greater Than the Sum of Its Parts

Ned Calonge — 2012-05-01

To capitalize on all the health benefits of providing evidence-based preventive services to individuals, there must be strategies that promote the delivery of these services at the population level. This is a critical underlying concept for the interaction between two distinct but interrelated working groups, well described by Fielding and Teustch, and acknowledged and supported by Congress in the Affordable Care Act: the U.S. Preventive Services Task Force (USPSTF) hosted by the Agency for Health Research and Quality (AHRQ), and the Guide to Community Preventive Services (the Community Guide) hosted by the CDC. For example, the USPSTF clinical recommendation supports colorectal cancer screening and the Community Guide recommends a number of health systems and community-based interventions designed to increase participation in colorectal cancer screening in the community. To maximize the health improvements associated with the early detection of colorectal cancer in the population, the service should be available, offered, and used by as many individuals in the appropriate age groups as possible.

Innovative Methods for Improving Measures of the Personal Environment

David M. Balshaw, Richard K. Kwok — 2012-05-01

A popular adage in thinking about disease risk states that “your genes may load the gun, but your environment pulls the trigger.” Nearly a decade following the completion of the Human Genome Project, it is clear that genetic variation is an important determinant of disease risk. Genome Wide Association Studies (GWAS) have identified numerous variants that have a positive association with several diseases. However, in prevention efforts, aside from gene therapy, it is not feasible to modify the genetic determinants of risk, only to modify the environmental factors that interact with those genetic determinants to cause disease. Thus, it is critical to determine what these environmental factors are in order to target prevention efforts.

Implications of the Energy Gap for the Prevention and Treatment of Childhood Obesity

William H. Dietz — 2012-05-01

The article by Wang and colleagues in this issue of the American Journal of Preventive Medicine provides important data that highlight the promise of prevention and raise the challenge of treatment in children and adolescents. The authors have calculated the caloric deficits necessary either to return the prevalence of child and adolescent obesity to 5% as it was in the 1970s, thereby achieving the Healthy People (HP) 2010 goal by 2020, or to reduce the current prevalence estimates by 10%, achieving the HP 2020 goal. As indicated in their article, the caloric deficits needed to achieve the HP 2010 goal by 2020 are 33 kcal/day for children aged 2–5 years; 149 kcal/day for those aged 6–11 years; and 177 kcal/day for those aged 12–19 years. To achieve the HP 2020 goal of reducing the prevalence of obesity by 10%, smaller deficits of approximately 5 kcal/day for the first group, 40 kcal/day for the second, and 31 kcal/day for the third, respectively, will be required.

Editorial Board

2012-05-01

Reaching the Healthy People Goals for Reducing Childhood Obesity Closing the Energy Gap

2012-05-01

Physical Activity and Physical Fitness Standardizing Assessment with the PhenX Toolkit

2012-05-01