Promoting Healthy Eating and Physical Activity for a Healthier Nation

Prevention Opportunities

• Levels of Prevention
  
  
• Socioecological Approach
  
  
• Essential Strategies
  
  
• Interventions
  
  
• Surveillance and Evaluation
  
  
• Partnerships
  
  
• Strategic Plans
  
  
• Policy
  
  
• Communications
  
  
• Professional Development
  
  

Levels of Prevention
Because poor dietary habits and physical inactivity are associated with many adverse health outcomes, most adults and children could benefit from interventions designed to improve their eating habits and increase their activity levels. Such intervention programs fall into three general categories: health promotion, primary prevention, and secondary prevention. The goal of health promotion is to help people establish an active lifestyle and healthy eating habits early in life and to maintain these behaviors throughout their lives. The goal of primary prevention is to help people who have risk factors for chronic disease (e.g., elevated blood pressure or serum cholesterol levels) prevent or postpone the onset of disease by establishing more active lifestyles and healthier eating habits. The goals of secondary prevention are to help people who already have a chronic disease cope with and control these conditions and to prevent additional disability by increasing their physical activity and establishing more healthful eating patterns.

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Socioecological Approach
To be most effective in the long run, public health programs should focus on health promotion as well as disease prevention. For example, by promoting breastfeeding to pregnant women and new mothers and supporting their efforts to breastfeed, public health organizations can help children develop healthy eating habits during infancy. Because appropriate physical activity levels and healthy eating behaviors should be instilled in childhood and maintained throughout life, prevention efforts that target older children and schools are equally important, as are interventions for adults who are inactive or have poor dietary habits even though they have not yet developed chronic diseases. All interventions should be appropriate to the target audience, and different strategies may be required to reach different segments of the population. Interventions may address individuals, institutions, communities, policies, or the environment and can be effectively implemented in various settings, such as schools, work sites, health care facilities, and places of worship.

Whatever population segment is targeted by an intervention, its members are also influenced by a social network consisting of family members, friends, colleagues, and acquaintances. Interventions have the best chance of succeeding if they are directed at all elements of this network simultaneously.^{20, 21} Increasingly, health promotion professionals are recognizing the dynamic interplay between individuals and their environments. Although lifestyle choices are ultimately personal decisions, they are made within a complex mix of social and environmental influences that can make healthier choices either more or less accessible, affordable, comfortable, and safe.^{22, 23, 24, 25}

Research has shown that behavior change is more likely to endure when a person's environment is simultaneously changed in a manner that supports the behavior change.^{21, 26} Therefore, interventions should address not only the intentions and skills of individuals, but also their social and physical environments, including the social networks and organizations that affect them.²⁷

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Essential Strategies
Guidelines for Comprehensive Programs to Promote Healthy Eating and Physical Activity (www.astphnd.org) is a document designed to help state and local health practitioners create comprehensive nutrition, physical activity, and obesity control programs.²⁸ These guidelines provide recommendations in seven major areas:

1. leadership, planning/management, and coordination;
2. environmental, systems, and policy change;
3. mass communications;
4. community programs and community development;
5. programs for children and adolescents;
6. health care delivery; and
7. surveillance, epidemiology, and research.

To make the best use of scarce resources for prevention, health agencies attempting to prevent chronic disease should use strategies that focus on highly prevalent risk factors that are modifiable through behavior change. Following are four behavior change strategies that meet this criterion. Each strategy can target one or more Healthy People 2010 objectives.

• Promote increases in physical activity. Exercise provides numerous health benefits and should be promoted to the most sedentary subgroups of the population.³
  
  
• Promote breastfeeding. Breastfed children have less risk for acute diseases of infancy and early childhood and a reduced risk of developing childhood obesity.⁸
  
  
• Increase fruit and vegetable consumption. Higher consumption of fruits and vegetables is associated with lower incidence of several chronic diseases, including cardiovascular disease and some cancers.⁴
  
  
• Reduce television-viewing time. A reduction in the length of time that children and adolescents watch television may reduce the risk for obesity among young people.²⁹

Physical Activity Strategies
The Guide to Community Preventive Services (www.thecommunityguide.org/pa) recommends five population-based strategies for increasing a population's level of physical activity.³⁰ These strategies include ways to achieve Healthy People 2010 objectives that deal with moderate and vigorous lifestyle activities for adults and young people (Chapter 22).⁴

• Community-wide campaigns. Large-scale, highly visible, multicomponent campaigns with messages promoted to large audiences through diverse media, including television, radio, newspapers, movie theaters, billboards, and mailings.
  
  
• Individually targeted programs. Programs tailored to a person's readiness for change or specific interests; these programs help people incorporate physical activity into their daily routines by teaching them behavioral skills such as setting goals, building social support, rewarding themselves for small achievements, solving problems, and avoiding relapse.
  
  
• School-based physical education (PE). School curricula and policies that require students to engage in sufficient moderate to vigorous activity while in school PE class. Schools can accomplish this by increasing the amount of time students spend in PE class or by increasing their activity level during PE class.
  
  
• Interventions that provide social support for physical activity in community settings. Interventions designed to promote physical activity by helping people create, strengthen, and maintain social networks that support their efforts to exercise more; examples include exercise buddy programs and the establishment of exercise contracts or walking groups.
  
  
• Interventions to provide people greater access to places for physical activity. Examples include building walking or biking trails and making exercise facilities available in community centers or workplaces.

NIH's National Heart, Lung, and Blood Institute (NHLBI) launched the Obesity Education Initiative (OEI) in 1991 to encourage Americans to adopt heart-healthy eating patterns and physical activity habits that will help to prevent overweight and obesity. The OEI also supports programs and activities related to the Healthy People 2010 objectives for reducing the prevalence of overweight, obesity, and physical inactivity. OEI's two-pronged strategy consists of a population approach, which focuses on preventing overweight, obesity, and physical inactivity in the general population, and a high-risk approach, which targets people who are experiencing, or are at high risk for, the adverse health effects and medical complications associated with overweight and obesity. For more information, visit the OEI Web site at www.nhlbi.nih.gov/oei/index.htm.

Strategies to Increase Fruit and Vegetable Consumption
High fruit and vegetable intake is associated with low dietary fat intake, and dietary fat is associated with both cancer and heart disease.^{5, 6} The Healthy People 2010 objectives related to fruit and vegetable consumption (Chapter 19) include recommendations to consume at least three servings of vegetables and two servings of fruit per day.⁴ Unfortunately, less than 25% of the U.S. population consumes at least five servings of fruits or vegetables a day. To increase fruit and vegetable consumption, CDC, the National Cancer Institute (NCI), the American Cancer Society (ACS), and three Department of Agriculture agencies are collaborating to expand federal support for the national 5 A Day for Better Health Program. Resources to help health organizations promote fruit and vegetable consumption can be found at www.5aday.gov, www.5aday.com, and www.5aday.org/pdfs/research/health_benefits.pdf.

Nutrition and Your Health: Dietary Guidelines for Americans (http://www.health.gov/dietaryguidelines/) serves as the principal federal policy document related to dietary choices. This joint publication of the Department of Health and Human Services and the Department of Agriculture is intended to serve the public in at least five ways:

• By helping consumers make dietary choices that will promote their well-being and help them avoid or postpone the onset of diet-related chronic diseases.
  
  
• By assisting federal, state, and local agencies in developing policies to guide the implementation of feeding and educational programs.
  
  
• By helping state and local agencies devise and implement regulatory policies and programs that relate to food, nutrition, and health.
  
  
• By assisting health care providers in primary disease prevention efforts.
  
  
• By guiding other domestic and international organizations in the implementation of food, nutrition, and health goals.

Strategies to Promote Breastfeeding
The Healthy People 2010⁴ objective relating to breastfeeding (Chapter 16) states: "Increase to 75% the proportion of mothers who breastfeed their babies in the early postpartum period, increase to 50% the proportion of mothers who breastfeed their babies for at least 6 months, and increase to 25% the proportion of mothers who breastfeed their babies for at least 12 months." Specific strategies to promote breastfeeding are outlined in the HHS Blueprint for Action on Breastfeeding, which can be found at www.cdc.gov/breastfeeding/00binaries/bluprntbk2.pdf. These strategies include

1. developing social support resources for breastfeeding women,
2. training health care professionals to promote breastfeeding among their patients,
3. establishing maternity care practices and policies that promote breastfeeding, and
4. establishing workplace programs and policies that promote breastfeeding.

Strategies to Reduce Television Viewing Time
On average, U.S. children 2-17 years old spend approximately 4.5 hours a day watching some kind of electronic screen, with 2.5-2.75 hours of that spent watching television.^{31, 32} National cross-sectional surveys have shown a positive association between the number of hours children watch television and their risk of being overweight.^{29, 31, 32} This correlation probably has several causes: television watching may displace calorie-burning physical activity, children may eat more while watching TV, television advertisements may induce children to consume more high-calorie foods and snacks, and TV viewing may reduce children's metabolic rate.^{33, 35-40}

Based on data from young people in grades 9-12, the Healthy People 2010 objective regarding TV watching (in Chapter 22) states: "Increase to 75% the proportion of adolescents who view television 2 or fewer hours per school day."⁴

Few studies have explored strategies for reducing children's TV viewing, and more testing and development of such strategies is needed before firm recommendations can be made. However, school-based programs have shown promise in helping to reduce children's TV viewing by providing means for parents and children to monitor and budget the time that children spend watching TV.^{37, 39}

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Interventions

Community-Based Programs
Community-based programs should use multiple approaches to provide people with the knowledge, skills, and attitudes necessary to eat a healthful diet and be physically active. These programs should work with local organizations to identify target populations^41-52 and should solicit full community participation in a comprehensive approach that addresses the physical, social, political, and cultural environments affecting community members.

Recommendations:

• Conduct community assessments to determine the dietary and exercise habits of residents, identify interventions that might help improve these habits, and identify community resources and potential partners that could help establish these interventions.
  

• Coordinate efforts to achieve Healthy People 2010 objectives among various groups and agencies.
  

• Encourage representatives of the intended population to participate in program planning, design, implementation, and evaluation.

• Identify relevant population subgroups; attempt to understand physical activity, nutrition, and obesity from their point of view; and develop community-based strategies and programs that are relevant and acceptable to them.

• Educate the public and policy makers about the importance of supportive environments.

• Promote broad social and environmental changes that complement individual change efforts. Examples of such activities include

• Promoting healthy food choices in away-from-home sites such as restaurants; fast-food outlets; school and work site cafeterias; vending machines; and sports, arts, and recreation venues.

• Encouraging restaurants to label heart-healthy foods on menus and encouraging vending machine operators to include a certain percentage of choices low in fat, sodium, and sugar.

• Coordinating community resources and identifying consistent, convincing, culturally appropriate, and scientifically sound nutrition and physical activity messages delivered through health professionals, grocery stores, places of worship, schools, the media, parks and recreational facilities and programs, food service operations, and other pertinent channels.

• Improving lighting and security in public exercise areas such as walking paths (sidewalks, trails) and bike paths.

• Involving the Department of Agriculture as a key partner through programs such as WIC.

• Recruiting nontraditional partners such as food producers and retailers, bicycle-pedestrian coordinators, transportation planners, local land/urban planners, trail coordinators, violence-prevention advocates, and neighborhood associations.

• Encouraging employers to adopt policies that support physical activity and good nutrition, such as offering flex-time and providing healthy food options at work-site cafeterias.

• Demonstrating model physical activity and healthy nutrition policies, procedures, and practices at the work sites of agencies.

• Ensuring that the public health benefits of both leisure-time and transportation-related physical activity are conveyed to transportation agencies, urban planners, building designers, and officials responsible for zoning and transportation-investment decisions.

School-Based Programs for Children and Adolescents
Coordinated school health programs have the potential to help young people adopt and maintain healthy eating and physical activity behaviors^53-56 and possibly to prevent and control obesity and other chronic diseases. Data from the National Health and Nutrition Examination Surveys (NHANES) reveal that the prevalence of obesity among U.S. children 6-19 years of age tripled in the past 20 years, to slightly more than 15%.^{57, 58} Information gathered through the Youth Risk Behavior Surveillance System (YRBSS) (www.cdc.gov/nccdphp/dash/yrbs/index.htm) indicates that more than a third of young people in grades 9-12 report not regularly engaging in vigorous physical activity. Meanwhile, the percentage that reported daily participation in school physical education classes declined from 41.6% in 1991 to 32.2% in 1999.⁵⁹

School-based programs should use a coordinated school health model to

• Provide students with opportunities to engage in healthy eating and physical activity behaviors.

• Help students develop the knowledge, skills, and attitudes necessary to adopt and maintain these behaviors.

• Integrate school-based physical activity and nutrition programs with family and community life.

Recommendations:

• Employ a full-time school health coordinator to work collaboratively with the education department on school health issues related to nutrition and physical activity.

• Collaborate with the department of education to employ a physical education/activity coordinator at the department of education.

• Educate policy makers, health practitioners, and the general public about the importance of requiring daily physical education classes and state-of-the-art nutrition education in the core curriculum in kindergarten through 12th grade.

• Collaborate with the department of education to provide support, training, and technical assistance to help schools implement CDC school health guidelines for promoting healthy eating⁶⁰ and physical activity⁶¹ and use the tools that support the implementation of these guidelines (e.g., the School Health Index^{62, 63} and Fit, Healthy, and Ready to Learn⁶⁴).

• Provide schools with the resources necessary to educate faculty and students about healthy eating and physical activity and implement curricula to promote healthy eating and physical activity.

• Encourage communities and businesses to support physical activity and nutrition programs for young people.

• Provide support, training, and technical assistance to help schools and community organizations achieve the following:

• Create food service programs that are consistent with USDA school meal program regulations and physical education programs that are consistent with the National Standards for Physical Education.⁶⁵

• Create a healthy school nutrition environment in which appealing, healthy, and nutritious choices are available whenever and wherever food and beverages are offered to students.

• Provide before- and after-school extracurricular physical activity opportunities such as physical activity clubs, intramural activities, and interscholastic sports.

• Integrate physical activity and healthy eating into before- and after-school child care programs (e.g., extended-day programs).

• Develop effective programs to increase the number of students walking to and from school.

• Develop and implement school health councils, which include community representation, to guide school health programs.

• Develop and implement effective employee health promotion programs and services.

• Evaluate school programs in healthy eating and physical activity and make improvements where needed.

Health Care Programs
One of the roles of health care programs is to provide effective preventive services, including services related to behavioral risk-factor modification.⁶⁶ To more effectively promote physical activity and healthy eating in the communities they serve, health care systems should collaborate with community partners to create an integrated approach.

• Work with health care systems to develop and use evidence-based standards of practice for delivering preventive services. At a minimum, health care plans should have standards of practice for assessing physical activity and nutrition and for assessing the effectiveness of clinical interventions. All children and adults enrolled in health care plans should have access to appropriate primary and secondary prevention care services related to physical activity and nutrition.

• Work with health care systems to ensure that their health care professionals are qualified to deliver preventive services related to physical activity and nutrition.^{67, 68}

• Work with health care systems to develop and evaluate prompts for counseling patients about nutrition, physical activity, and body weight regulation.

• Promote policies that either require or provide incentives for health care systems to include preventive services related to nutrition and physical activity as part of their benefit packages. Examples of policies that provide such incentives include reimbursing providers for preventive care and basing a health care system's quality-of-care rating at least in part on the quality of the preventive care it provides.

• Help health care systems coordinate their preventive care activities with community efforts to promote physical activity and healthy nutrition. The collaboration of the North Carolina Prevention Partners (www.ncpreventionpartners.org) illustrates how such a coordinated effort might function.

• Work with health care systems to include nutrition and physical activity indicators in the surveillance data they collect. These indicators can be used to evaluate the effectiveness of interventions to increase physical activity or improve nutrition among patients in the system.

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Surveillance and Evaluation
Surveillance of a population's dietary practices and physical activity levels is necessary for quantifying problems, understanding the scope of these problems, identifying trends, targeting subgroups for intervention, guiding planning, evaluating the impact of interventions, informing the public, and influencing public policy.^69-79 Validated indicators of nutrition and physical activity and the life stages for which each is appropriate are shown in Table 2. This list is partial and could be modified according to a particular health department's interests.

In addition, program-specific and community-level indicators may be useful in targeting areas for intervention and monitoring progress in meeting specific program objectives. For example, information about the food choices available at various sites in a community could be useful in planning community nutritional interventions. Physical activity indicators could include policies related to community use of school facilities after school hours or required physical education classes for high school students.

To establish or increase their capacity to carry out dietary and physical activity surveillance, programs should collect data on a regular basis and incorporate existing surveys into their data collection efforts whenever possible. Examples of such surveys include the Behavioral Risk Factor Surveillance System (BRFSS) [www.cdc.gov/brfss/] for adults, the YRBSS [www.cdc.gov/nccdphp/dash/yrbs/index.htm] for adolescents, and the Pediatric Nutrition Surveillance System (PedNSS) [www.cdc.gov/nccdphp/dnpa/pdf/pednss.pdf] for children in the WIC program. Programs should also consider using state- or local-level surveys that include nutrition and/or physical activity data. Because surveillance data are so essential to the success of programs, programs should

1. establish standards for data analysis and timely reporting and
2. provide training and technical assistance to help program personnel collect and analyze data.

Evaluations should describe how an intervention was conducted (i.e., process evaluation) as well as how successful it was in meeting its objectives (i.e., outcome evaluation). Because it is often not possible to see a short-term change in the ultimate outcome measure, program planners may need to identify intermediate outcome measures. For example, intermediate outcomes for a nutritional intervention aimed at increasing fruit and vegetable consumption might be increased awareness of the importance of fruit and vegetable consumption. Even when interventions have been implemented, evaluated, and shown to be successful in a prior setting, ongoing evaluation is essential to ensure that the program is working well in the current setting.

Table 2. Possible Surveillance Indicators for Nutrition and
     Physical Activity Programs

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Partnerships
Strategic partnerships that can serve the goals of all partners are very important in leveraging limited resources. Health departments and community health centers can foster such partnerships by developing coalitions that include local health departments, other health care providers, and various partners capable of providing or supporting programs that promote better nutrition and greater physical activity. These coalitions should be as inclusive as possible and include both traditional partners, such as hospitals and national health organizations, and nontraditional partners, such as restaurants, grocery stores, and transportation agencies.

One example of a successful partnership is a collaborative effort between the New York Division of Public Health and the New York Academy of Medicine that produced The Pocket Guide to Cases of Medicine and Public Health Collaboration (www.nyam.org/divisions/publichealth/guide.shtml). Available in both a print version and an online version, the guide describes more than 400 instances of medical and public health collaboration. Another example is the North Carolina Prevention Partners project, Building Alliances for Health Systems to Integrate Preventive Care Services (BASIC) Benefits (www.ncpreventionpartners.org). This Web-based system coordinates and displays a variety of health-related information and programs that are relevant to North Carolina.

Community coalitions are another type of partnership that proved useful in Missouri, where the Bootheel Heart Health Program provided community-based activities designed to help residents of a rural, medically underserved area of southeastern Missouri decrease their risk for cardiovascular disease by, among other things, exercising more and eating more healthful foods.^{51, 52}

Web sites for organizations that can serve as partners for nutrition and physical activity programs are listed in Table 3.

Table 3. Potential Partners for Comprehensive Nutrition and
     Physical Activity Programs

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Strategic Plans
A strategic plan for promoting healthy diets and physical activity should describe how the comprehensive program will coordinate multiple categorical programs that in any significant way address nutrition, physical activity, or obesity prevention. Key elements should include a surveillance system for monitoring progress; a public communication and education program focusing on all segments of the population; coordination with other programs and services (e.g., cardiovascular health, diabetes, cancer control, minority health, and aging/social services); and strategic partnerships with state and local government entities, academic institutions, and private organizations. Potential partners for whom nutrition, physical activity, and obesity prevention are relevant underlying issues could include programs or organizations focusing on diabetes, cardiovascular disease, neighborhood safety, or livable communities. The plan should also identify methods of working with government leaders and establish the organizational support and infrastructure necessary to promote policy-level interventions such as making communities more "activity friendly."

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Policy
In addition to convincing people to be more physically active and eat a healthier diet, state and community programs should work to create environments, systems, and policies that

• Serve as passive inducements to being physically active and eating a healthy diet.
• Eliminate barriers to being active and eating a healthy diet.
• Provide explicit support, reinforcement, and inducements to making healthy choices such as taking stairs rather than riding elevators or eating fruits or vegetables instead less healthy foods.
• Change cultural and organizational norms for physical activity and body weight.
• Establish themselves as partners in planning and decision-making on environmental and policy issues that affect people's eating and physical activity habits.

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Communications
Health communications efforts should have three main goals:

1. to educate the public about the importance of diet and exercise and motivate them to eat healthier and engage in more physical activity,
2. to motivate relevant groups and policy makers to create policies and environments that support healthy eating and increased physical activity, and
3. to eventually change social norms related to eating and activity.

Potential audiences for communications activities might include others within the agencies, decision makers, health care providers, the general public, specific segments of the population, policy makers, the media, business leaders, and partners. Because each audience will have different concerns and "cultures," health communicators will need to be adept at defining their various audiences and at designing culturally appropriate communications strategies and messages for each. The CDCynergy program (www.cdc.gov/cdcynergy) can assist programs in planning communications activities.⁸⁰

Because eating and exercise habits are complex behaviors linked to larger social, cultural, political, economic, and environmental factors, health communications activities should be part of a larger plan that addresses these other factors. Social marketing provides a useful framework for such a broad approach to health communications. Resources on social marketing can be found at http://socialmarketing-nutrition.ucdavis.edu/home.htm, www.turningpointprogram.org/Pages/socialmkt.html, and http://www.hc-sc.gc.ca/english/socialmarketing/index.html

Health communications messages should be as specific as possible (e.g., "Eat 5 a Day" rather than "Eat a Healthy Diet"). Because members of the general public cannot be expected to know what terms like "healthy diet" and "moderate physical activity" mean, program planners and health communicators should determine how their audiences perceive such concepts and define them more clearly if research shows this to be necessary. Research should include formative research (e.g., focus groups), pretesting of concepts and messages, and monitoring during the implementation of the program.

The Weight-Control Information Network (WIN) is a national service of NIH's National Institute of Diabetes and Digestive and Kidney Diseases. WIN was established in 1994 to raise awareness and provide up-to-date, science-based information on obesity, physical activity, weight control, and related nutritional issues to health professionals, people who are overweight or obese, the media, Congress, and the general public. WIN Notes, WIN's newsletter, features information on obesity and weight control research, new initiatives and programs, professional organizations, and materials and resources available from WIN and other organizations and agencies. Other publications include brochures, fact sheets, article reprints, conference and workshop proceedings, and materials developed by NIDDK on obesity and nutrition. For more information, see www.niddk.nih.gov/health/nutrit/win.htm.

The California Nutrition Network (www.dhs.ca.gov/cpns/network/index.html) offers an example of how states can design appropriate materials for specific populations. For several years, this group has produced social marketing campaigns that focus on the dietary habits of various target populations.

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Professional Development
Staff should be familiar with recent scientific research related to nutrition and physical activity, as well as with current guidelines about what constitutes healthful dietary and physical activity behaviors. At a minimum, those who work with surveillance data should be familiar with current technology related to the measurement of these behaviors and associated environmental indicators. Those who work with programs may require training on behavioral and environmental motivators, program development and partnering strategies, program evaluation, social marketing, and communications. Networking with members of nutrition and physical activity programs in other states is another way for program personnel to stay abreast of new developments in their field.

Examples of training opportunities in physical activity include the Physical Activity and Public Health Courses. This series includes the 6-day Public Health Practitioner's Course on Community Interventions, the 8-day postgraduate Research Directions & Strategies course conducted annually by the University of South Carolina, and the national 5 A Day training conducted twice yearly by NCI and CDC. Various national organizations also offer opportunities for professional development in areas related to physical activity and nutrition. Such organizations include the American College of Sports Medicine; the American Alliance of Health, Physical Education, Recreation and Dance; the Society for Public Health Education; the Society for Nutrition and Education; the American Public Health Association; the Social Marketing for Public Health Conference; and the American Dietetic Association. The Web site of CDC's Division of Nutrition and Physical Activity (www.cdc.gov/nccdphp/dnpa) provides information on CDC-funded research and practices in these areas. CDC also offers monthly nutrition and physical activity teleconferences. National training resources on obesity include health care provider training by the Centers for Obesity Research and Education (www.uchsc.edu/core/index.htm) and weight management training for dietitians provided by the Commission on Dietetic Registration (www.cdrnet.org/whatsnew/certificateofTraining.htm).

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