Patricia Coleman, Nutrition and Health Programs Team Leader

1. Patricia Coleman, Nutrition and Health Programs Team Leader

2. prevalence of young child Overweight and Obesity in the us affiliated Pacific Region: a meta Analysis from the children’s healthy living program (chl)* Rachel Novotny1, Marie Kainoa Fialkowski1, Fenfang Li1, Donald Vargo2, Yvette Paulino3, Patricia Coleman4, Andrea Bersamin5, Claudio R Nigg1, Jodi Leslie1, Rachael Leon guerrero3, Jonathan Deenik1, Jang Kim4, Lynne R Wilkens1 1university of Hawaii, 2american samoa community college, 3university of guam, 4northern marianas college, 5university of alaska, fairbanks Introduction: US NHANES is not conducted is US Affiliated Pacific (USAP) Region (USAP Islands, Hawai`i , Alaska). Method: A meta-analysis of published literature and publicly available agency reports was conducted to estimate overweight and obesity prevalence of 2-8 year (y) old USAP children. Contiguous US data (NHANES) served as reference. Literature search was limited to resources in English and 2-8y USAP children data from 2000 to 2013 and used CDC 2010 overweight and obesity reference data. USAP region sources (n=23) and NHANES articles (n=3; the contiguous U.S reference) included. Data were disaggregated into single years of age. The children measured for the age group were divided equally and the prevalence was assigned to each individual age. A mixed model regressed the prevalence on a polynomial in age, accounting for the prevalence variance and another model compared jurisdictions. Results: Overweight plus obesity increased from 21% at 2y, to 39% at 8y (p<0.0001) for the USAP. In comparison, combined overweight plus obesity increased from 24 % at 2y to 35% at 8y (p<.0001) for NHANES. USAP data showed with a sharp increase in prevalence at 5y. Obesity alone increased from 10% at 2y, doubling to 24% at 8y (p<0.0001)whereas overweight prevalence was stable from 2y (13%) to 8y (15%). Discussion: Further examination, monitoring and understanding of USAP young child obesity is needed. *to be presented at American Society of Nutrition Annual meeting in San Diego, April 2014 & abstract published in FASEB journal. Paper submitted to AJPH.

3. Methods Meta-analysis of published literature and publicly available agency reports for Hawaii, Alaska, and US-Affiliated Pacific Islands English only, 2-8 year olds Year 2000 & newer, CDC overweight and obesity reference data Data disaggregated into single years of age

4. Methods cont. Children measured for the age group were divided equally and prevalence was assigned to each individual age Mixed model regressed the prevalence of a polynomial in age

5. Results OWOB increased from 21.0% at 2y to 39.2% at 8y (p<.0001) for the USAP NHANES increased from 24.2% at 2y to 34.8% at 8y (p<.0001) Sharp increase in prevalence at age 5y USAP obesity alone increased from 10.2% at 2y to 23.6% at 8y (p<.0001)

6. CHL Population

7. U.S. Affiliated Pacific RegionNeed CHL Annual Meeting, Guam June 2013 Obesity - minimal data, no NHANES Capacity - few trained professionals Unique geography and culture - need culturally tailored approach

8. CHL Vision Children from the Republic of the Marshall Islands We envision sustainable community-based systems and environments to raise healthy children in the Pacific Region

9. CHL Mission Tafuna Elementary, American Samoa, April 2013 In partnership with our community, our mission is to elevate the capacity of the region to build and sustain a healthy food and physical environment to help maintain healthy weight and prevent obesity among young children in the Pacific region

10. CHL Goal Children from Yap State, Federated States of Micronesia The goal of CHL is to build social/cultural, political/economic, and physical/built environments that will promote active play and intake of healthy food to prevent young child obesity in the Pacific Region

11. CHL Management Structure Program Steering Committee Lead Site Co-I : Deenik, Kim, Bersamin, Leon-Guerrero/Barber, Novotny, Vargo/Ropeti Principal Investigator Novotny External Advisory Committee Jennifer Anderson Kathryn Kolasa Suzanne Murphy Wendy Snowdon Boyd Swinburn Local Advisory Committees LG Dir. Chair: Currie, Samson, Taro; Manglona; Sparrow, Yudin, Gallo, Aga Data Center Lead: Wilkens Data Coordinator: Li Performance Sites FAS: FSM, RMI, Palau; CNMI; Alaska; Guam; Hawaii; Am. Samoa Training / Education Center Lead: Dunn / Fialkowski Education Coordinator: Leslie / Delormier Coordinating Center Program Director: Novotny Assistant Program Director: Fialkowski Program Administrator: Yan Conference Coordinator: Chun IT Manager: DeBusk External Communication Center Lead: Hollyer / Takahashi Intervention Center Lead: Nigg / Braun Intervention Coordinator: Butel Situation Analysis Center Lead: Fialkowski / DeBaryshe

12. CHL Target Population Grant requirement: children ages 2 – 8 y Head Start Preschool Day Care Kindergarten Community Health Centers Community Centers Community Events Supplemental Feeding Program for Women, Infants, & Children Images from CHL brochure, courtesy of Center on the Family

13. CHL Objectives • Conduct program / data inventories & situation analysis – Situation Analysis Work Group • (Degree) Train 22 professionals & paraprofessionals in obesity prevention – Training Work Group • Develop Pacific food, nutrition & physical activity data management & evaluation system – Data & External Communications Work Groups • Develop & conduct an environmental intervention (to prevent, maintain or decrease young child overweight & obesity in the Pacific Region) – Intervention and External Communication Work Groups • Evaluate the community - based primary - prevention environmental intervention – Data Center Work Group • Incur at least one obesity prevention policy change per state / jurisdiction – Program Steering Committee Work Group

14. CHL (6 behavioral outcomes, 3 health outcomes) Primary 1. Sleep by 15 min/day 2. Moderate to vigorous physical activity by 10 min/day 3. Fruit & vegetable intake by 1 serving/day (1/2 c/day) 4. Water intake by ½ cup/day 5. Sedentary behavior (screen time) by 10 min/day 6. Sweetened beverage intake by ½ cup/day 1. Prevalence of obesity by 8% (0.10 kg/m2 decrease in BMI z- score) 2. Waist circumference by 2% Secondary 3. Acanthosisnigricans by 5% Positive acanthosis nigricans screen, CHL Study

15. Effective Evidence-Based Strategies from Randomized Controlled Trials

16. ANGELO –Analysis Grid for Elements Linked to Obesity (Swinburn and colleagues) Healthy Eating Decrease in SSB intake Increase in water intake Increase in fruit & vegetable intake Physical Activity Decrease in leisure screen time Increase in sleep Increase in physical activity

17. Top Strategies from Communities (Nov 2011-Feb 2012)

18. MERGE -- Much of what the community wants is supported by the literature

19. PRIORITIZE - Communities prioritized the merged list of strategies (May-June 2012) Merged list of strategies posted on flip chart paper Presented to 10 selected communities, 2 each in: • Alaska • American Samoa • CNMI • Guam • Hawaii Participants prioritized based on • Importance • Feasibility (Do-ability)

20. FORMULATE– Intervention Community Action Planning (LAC) • Bring together key stakeholders, including parents, teachers, and leaders to implement the strategy • Adapt the strategy to the locale • Promote and implement the strategy • Establish a mechanism to monitor fidelity and outcomes • Use data to improve implementation

21. Other communities are testing interventions to reduce childhood obesity, ANDthey are willing to share their materials and ideas!

22. In implementing these strategies, CHL: • Partners with, supports, and “adds value” to existing programs that are conducting activities related to our 6 behavioral outcomes. • Builds local capacity to sustain programs and policy changes. • Promotes a common CHL message. • Collects data on the timeline of implementing strategies and on the extent to which strategies are implemented at given time points.

23. Cross-cutting Functions Review assessment data for policy & physical environment related to the 6 CHL behaviors Partner & advocate for environmental change Promote the CHL message Train the trainers

25. CHL TEAM CNMI Jang Ho Kim, TaynaBelyeu-Camacho, Rose Castro, Jesse Deleon Guerrero, Marilynn Duenas, Randall Nelson, & me 

26. CNMI work w/role models (RM) Village focused instead of CNMI-wide focus RM identified by key informants, knowledge of community Empowerment of stakeholders/role models Training and technical support Building on assets, strengths, influences of role model group—integral role in driving the intervention Diverse backgrounds

27. Village Logos

28. TASA Role Models

29. Enhancing the Built Environment in Kagman

30. Policy: Child Care Licensing Regulations Policy & Advocacy Training First training slated for May-demonstrate burden of COWOB, critical role they play-get buy-in Include child care administrators, owners, managers, and child care providers Write the policy in Subsequent trainings to focus on implementation of one or two CHL behaviors CCDF benefits • Require each child care center to have policies that focus on the implementation of the CHL behaviors • Require procedures/plans for implementation • Align inspection checklist with policy requirements • Mobilize partners for support • Get approval from governor

31. Prevalence SurveyFreely Associated States: Palau, Marshalls, Chuuk, Kosrae, Pohnpei, Yap Determine the prevalence rates of underweight, overweight, and obesity in a representative sample of young children, ages 2 – 8y, from each jurisdiction Provide descriptive information on similar measures as CHL Intervention Study Approximate sample size 200 per jurisdiction Marshalls, Kosrae, Pohnpei, Chuuk, Yap, Palau) Data: Anthropometry, AcanthosisNigricans, Accelerometry, Questionnaire (Sleep etc...),Food and Activity logs, Community obesity prevention environmental assessment, Food & Utility cost survey Most Survey elements completed in Pohnpei (Oct 28-Nov 8, 2013) and RMI ( Jan 1-Feb 4, 2014) Palau survey: April 7-18, 2014; Chuuk Survey July 14 to Aug 14, 2014; Yap October 2014; Kosrae Jan 2015

32. Capacity Building Through Training • I.CHL Scholarship Program • Provide academic degree training for indigenous students in CHL region- 2 from each jurisdiction, including 2 from each state of Freely Associated States of Micronesia II. CHL Capacity Building Program for the Pacific Region Help develop sustainable, culturally appropriate, nutrition courses & programs & within existing academic institutions in the region

33. CHL Students – Cohort 1

34. CHL Students – Cohort 2

35. CHL Phases Training 3,919

36. Children’s Healthy Living Program Promote Outcomes Environmental Changes Social/Cultural Env. Examples: • Family, teachers, church leaders, other respected role models setting example of healthy living • Healthy • Food Intake • Decrease in sugar-sweetened beverage intake • Increase in water intake • Increase in fruit and vegetable intake Obesity Prevention Community-Based Environmental Intervention & Policy Change Data Systems Training/Education • Political/Economic Env. • Examples: • Influence leash laws Overall Outcome: Healthy Young Child • Physical • Activity • Decrease in recreational screen time • Increase in sleep • Increase in physical activity • Physical/Built Env. • Examples: • Ensure water fountains are available & maintained

37. Si yu’usmaaseyanolomwaay!