Author: Carly Wender

Childhood obesity is a widespread concern for the country, especially for southern states, where the prevalence is considerably higher. For example, 39% of children in South Carolina are overweight and/or obese, which is almost double the national average (20%). For this reason, the Public Health department at the University of South Carolina has started an annual childhood obesity lecture. For the second installment, they invited Dr. Brian Saelens, a professor of pediatrics, psychiatry, and behavioral sciences at the University of Washington in Seattle. The purpose of his talk was to discuss his current research on family based care and weight management interventions.

Often based in family behavior therapy (FBT) techniques, popular interventions targeting pediatric weight management via their parents employ four common strategies: self-monitoring of food and activity, goal-setting and contingent reinforcement, environmental control, and parent modeling. These techniques and interventions have shown some success, but have not met their potential for change as they are cost and labor intensive, they are limited to certain populations, and most improvements are not long lasting after conclusion of the intervention. Dr. Saelens proposed an alternative where parents and families who have completed the intervention become peer leaders and run the intervention for other parents and families. This “pay it forward” mentality should maintain the intensity and comprehension of the intervention, reduce costs, improve reach and availability, and sustain longer lasting outcomes.

A pilot study testing the efficacy of this idea, called Parent Partnership Project, showed limited results. There was no preference among parents or kids whether professionals or other parents acted as their leaders during the intervention and it was dramatically more cost effective. However, the sample was too small to definitively show better weight related outcomes in the peer leader group over the professional-led group. Dr. Saelens and his group were able to use this pilot data to secure federal funding to implement a much larger study. Over the course of this long-term study, families will be randomly assigned to receive treatment by peers who’ve completed the program or by professionals. So far, they’ve had more than 50 families begin treatment and 10 have committed to becoming peer interventionists.

This bold new style of intervention with family weight management is brilliant for so many reasons. Above all, parents leading other parents will allow for longer lasting sustainability of weight management techniques utilized in the intervention. When parents are tasked with teaching other parents, they themselves have an accountability to continue the techniques they’re teaching in their own family. It’s analogous to how being a sleepaway camp counselor is the best training for teenagers heading off to college. They cannot fulfill their jobs of taking care of young campers without also taking care of themselves. Furthermore, for every family who completes the intervention and decides to become a peer leader, there is an exponential increase in families getting this intervention. This kind of creative thinking is what’s necessary to truly improve the obesity epidemic facing us today.

Sedentary behavior is a major contributor to rising rates of obesity, diabetes, cardiovascular disease, and other related health problems in the US. America Walks is a non-profit organization that fights against this threat by improving walkability in communities across the country. In collaboration with local governments and organizations, they work to promote and improve pedestrian access, safety, and general use of outdoor space. In an effort to educate others on their successes and failures, they’ve put together several webinars, including one on October 11, 2017 entitled “Friends and Allies in the Walking Movement”. This latest webinar featured representatives from three organizations working to improve walkability in their own cities.

Kim Irwin, the Executive Director of Health by Design, discussed several ways the organization has improved walkability in Indianapolis and surrounding communities. One initiative she highlighted, called “Moving INDY Forward”, engaged heavily with community members and utilized “walking audits”, where they walked around the city talking with local business owners, customers, and city officials. This initiative was successful because the organization took advantage of its connections to the local population to find out what projects were most pertinent to the community and smaller problems that they could solve relatively quickly. A similar group in California, called WALKSacramento, would not have found the success they have without the help of their collaborators. Executive Director Kirin Kumar detailed how their multidisciplinary team consisted of air quality management personnel, private companies, public officers, UC Berkeley, and other universities. Together, this group educated their community, created guidelines to healthier city planning, and received federal funding to put those guidelines into practice. Finally, Honolulu Walks addressed the alarmingly high rate of senior pedestrian injuries and deaths in their city by creating a unique partnership. As Colby Takeda explained, the program worked by infusing the energy and enthusiasm of the youthful generation with the wisdom and curiosity of their senior counterparts. By pairing on a photography project, they learned to see the city through each other’s eyes and saw how enjoyable and safe it can be to walk through.

While the three programs discussed in this webinar used different tactics to address different problems facing their respective cities, they shared a common value of collaboration and teamwork. Public health seems to be a field where collaborations are inherent. For a public health researcher to implement a physical activity intervention, s/he would greatly benefit from recruiting the help of an exercise physiologist to lend the expertise on physical activity s/he may not have. It seems common sense that collaboration should be inherent in research, as no one can have expertise in every aspect involved in his/her area of interest. Instead, exercise scientists often run their research without the consultation of public health researchers because they strive for statistical significance in highly controlled studies, and focus much less on the real-world implication of their results. Researchers should strive for the same values of teamwork that children are taught when they first start school.

Physical inactivity is a plague affecting the entire world today, not just the United States. The World Health Organization (WHO) recognizes this crisis and is committed to leading the world in a treatment plan.  In a webinar, conducted by the ISBNPA and ISPAH, two international societies for physical activity and health, Dr. Fiona Bull (WHO) described their detailed plan of how to combat physical inactivity in the world called the Global Action Plan on Physical Activity (GAPPA).

The ultimate goal of GAPPA is to decrease insufficient physical activity (PA) by 10% relative to each country involved. The four thematic objectives in this plan are to create active societies, environments, people, and systems. The core part (Part 3) of the plan outlined how specific actions fit into each of these objectives. For example, an active environment is achieved by improving urban design, improving safety, and fast-tracking those methods through necessary political channels. The final part of the plan is the practical application of the theoretical ideas. While this section is currently under development, it will link GAPPA to the already established Global Physical Activity Toolkit in the hopes of providing countries with tangible resources to accomplish each objective.

During the second half of this webinar, Dr. Charlie Foster (ISPAH President) and Dr. Jo Salmon (ISBNPA Past-President) facilitated a discussion to address weaknesses or confusing areas of GAPPA. One topic that came up repeatedly was how countries begin to take action and how to evaluate their progress when each country has a different starting point. Dr. Bull emphasized a portion of the plan that discusses “best buys,” or successful interventions the WHO deemed most cost effective in their analysis. By far, the two best strategies were mass media efforts and physician-based care from primary care professionals. Another interesting point that came up during the discussion was the question of how to set the PA goals for each country in 2030. On the one hand, should it be “bigger and bolder” than the goal set for 2025, assuming that the basics have been set and have started working? Or should it be a more conservative goal that may be more realistic and within reach? There wasn’t enough time in this short session to come up with a convincing answer. Questions and dilemmas about GAPPA, including those just mentioned, are also questions of interest to public health researchers. Their work should continue to guide the work of WHO and similar organizations.

As someone new to the public health field, learning about the logic model in class was somewhat frustrating because it didn’t feel practical. Too often we read research that describes a perfectly realistic model but does not translate into palpable changes in PA or nutrition. GAPPA is a detailed, comprehensive logic model that details specific actions that will be used in implementation. It was perhaps the first time I fully understood the purpose of a logic model and how it can drive action to reach a goal.

America Walks, a national, nonprofit organization aimed at improving the walkability of communities across the country, sponsors and promotes research in line with those goals. One webinar they conducted, titled “Lessons from Dissemination and Implementation Research for Interventions Promoting Walking and Walkability,” featured two prominent researchers in the field, with lots of experience introducing walking interventions into different communities, who detailed lessons they’ve learned from their work in public health.

Dr. Ross Browson, a public health research at the University of Washington at St. Louis, spoke about the unique field of dissemination and implementation (D&I) research. The key characteristics of D&I research were multilevel complexity, scalability and sustainability, adaptiveness, and respect for diverse approaches. In other words, he argued that intervention programs need to fit the size and complexity of the community and need to be able to change based on how the community responds. In his experience, the most critical issues arose in the connection between research and public policy and whether those areas worked harmoniously. His advice to clinicians looking to implement interventions was to utilize hybrid designs that test both effectiveness and implementation simultaneously and to keep several “key ingredients” in mind when designing studies and applying for grants to fund them. These ingredients included clearly defining the evidence-based practice that will be utilized, using a D&I framework, documenting each member of the team’s D&I experience, and measuring more than one effectiveness endpoint or goal.

Dr. Jacqueline Kerr, a researcher in family medicine and public health at the University of California at San Diego, spoke about her experience in developing peer-led physical activity (PA) programs for seniors in retirement and senior center settings. Her group found great success in decreasing PA decline in this population and successfully partnered with a pedestrian advocacy organization (WalkSanDiego) to clean pedestrian bridges and create safer crosswalks and sidewalks. The most impactful aspect of her study, which she highly encouraged other practitioners to include in their interventions, was in-person counseling and employing educated, motivated, and excited staff to run the day-to-day programs. She also suggested using rolling recruitment throughout the program and creating a clear plan for how to seamlessly transition leadership so as not to interrupt the program.

The most interesting part of this webinar was the similarity between the two talks, primarily in relation to the hurdles they had to overcome. Their success was directly dependent on the community they came into, how they were received by the people in that community, and their ability to adjust accordingly. As exercise science researchers, we often feel far removed from study subjects. We publish papers about the benefits of exercise and cannot fathom why that doesn’t convince people to change their behavior. Public health takes almost the opposite approach and it’s fascinating to see how different problems arise. Different techniques from different fields need to work together to overcome inactivity.