6 Chapter Six: Community Interventions in Obesity Prevention

Authored by: Sherri M. Cirignano, MS, RDN, LDN

Introduction

Community interventions that work towards the prevention of overweight and obesity are implemented at the local, state and/or national level and can be found in a variety of settings, targeting populations that include individuals throughout their lifespan. Some of these interventions were created for the specific purpose of creating healthful choices and/or environments that would promote a decrease in overweight and obesity, while others are longstanding initiatives that have been updated to include healthful changes to work towards obesity prevention. In this chapter, we will explore community interventions in a variety of settings and their associated target population and what is known about their rates of success.

Settings for Obesity Prevention Interventions

“To reverse the obesity epidemic, community efforts should focus on supporting healthy eating and active living in a variety of settings.”¹

Early Care Sites

A majority of young children, ages birth through age 5, spend time each week away from their parents or guardians at an early care site. It is estimated that 3 out of 5 children, or about 12.5 million children, in this age category receive center-based care at least once a week.² With a national rate of obesity among 2-4 year old children at 12.8% and an even higher rate of 15% in children of the same age range who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in 2020, early care sites are an ideal setting to assure healthy eating and physical activity practices are in place to work towards decreasing these numbers.³

All 50 states and the District of Columbia have state-mandated licensing requirements for early care sites to operate and may already include those that promote healthy eating and physical activity. The Centers for Disease Control and Prevention (CDC) has developed evidence-based standards for states to include in their licensing requirements that will promote healthy behaviors and the prevention of obesity. The CDC reports on the progress of states in adopting these high-impact obesity prevention standards through State Licensing Scorecards. There are 47 total standards that can be adopted focusing on the following topics: healthy infant feeding; nutrition; physical activity; and screen time limits. Based on these four issues, state scores can have an overall total score of 100. In 2019 state scores ranged from a high of 80 out of 100 to a low of 30 out of 100.⁴ The CDC also offers a guide to assist states with ways they can “embed” obesity prevention standards at their early care sites. This guide, the Spectrum of Opportunities Framework, includes ways to incorporate healthful practices that encompass healthy eating, physical activity, breastfeeding, and reduced screen time among young children in early care settings.⁵

The CDC offers funding for several obesity prevention programming efforts for early care sites. They include the State Physical Activity and Nutrition (SPAN) Program and the Racial and Ethnic Approaches to Community Health (REACH) program. SPAN is a CDC grant program that provides funding for 16 statewide evidence-based initiatives that focus on improving nutrition and physical activity in the state’s early care sites.⁶ REACH, started in 1999, is a national CDC program that works towards reducing racial and ethnic health disparities such as diabetes and obesity. REACH programming between 2014-2018 has improved healthy access to food and drink to over 2.9 million people and increased physical activity opportunities for about 1.4 million people.⁷

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a national program provided by the Food and Nutrition Service department of the United States Department of Agriculture (USDA.) WIC was created in 1974 to provide nutritious foods, nutrition education and healthcare referrals to low-income pregnant and postpartum women and infants, and children to age 5 who are at nutritional risk. WIC also promotes breastfeeding as part of its nutrition education programming. States receive federal grants from the USDA to implement WIC in locations such as county health departments, hospitals, mobile clinics and community centers throughout their state.⁸

WIC designates specific foods that participants can receive. Changes to the WIC food package were implemented in 2010. As a result of these revisions, researchers have found an increase of availability of healthy foods by some WIC-authorized vendors,⁹ an increase in consumption of whole grain products, fruits and vegetables and a decreased intake of juice.¹⁰ During the time period of 2010-2016, there was also a decrease in the prevalence of obesity and severe obesity in WIC participant children aged 2 to 4 which may be due to the changes in the food package.¹⁰ Continued research on this topic is needed.

Other nationally run programming that include an element of obesity prevention includes Early Head Start and Head Start, administered by the Administration for Children and Families, an agency within the US Department of Health and Human Services. Head Start participants receive healthy food through either the Child and Adult Care Food Program (CACFP) or the National School Lunch Program (NSLP) and the Head Start program is required to “actively engage in obesity prevention both in the classroom and through its family-partnership process.”¹¹ The CACFP offers nutritious food at early care sites with meal and snack standards based on the Dietary Guidelines for Americans.

Schools

Children aged 5 and older spend a significant amount of time at school, making it an ideal location for implementing obesity prevention measures and assuring an overall healthful environment that promotes nutritious foods and physical activity. This is important for all children, but is especially important for lower-income and minority children who have been found to be at a higher risk for obesity in comparison to other children.¹² The 2022 report The State of Obesity: Better Policies for a Healthier America from the Trust for America’s Health states that 17% of children in the US live below the poverty level and up to 23% of children are food insecure.¹¹ Obesity levels in US children continues to be elevated. Between 2017-2020, data indicate obesity prevalence was 20.7% among 6–11 year-old children and 22.2% among 12-19 year old children. These numbers rise to a prevalence of 26.2% among Hispanic children and 24.8% among non-Hispanic Black children during the same timeframe.¹³

National efforts that have worked to reverse the obesity epidemic for children include the Healthy, Hunger-Free Kids Act of 2010 (HHFKA). The primary goal of this legislation was to set policy and authorize funding to improve child nutrition in USDA’s primary child nutrition programs including the NSLP, the School Breakfast Program, (SBP) the Summer Food Service Program, WIC, and the CACFP. Since its implementation, which was required of the NSLP by 2012, researchers have looked at the possible effects of the HHFKA over the past several years. Findings indicated an overall increase in the quality of school meals,^10,14 and in improved consumption of school meals.¹⁰ In addition, one study found a “substantially” decreased risk of obesity prevalence among children in poverty.¹² These findings overall indicate that sweeping federal policy changes such as the HHFKA can potentially result in long-term benefits.

In 2019, through the NSLP, schools provided over 4.8 billion lunches to children nationwide¹⁵ and through the SBP, provided over 2.4 billion breakfast meals.¹⁶ Other federal programs that provide opportunities to increase healthful choices for children include the Summer Food Service Program, serving free healthy meals and snacks to children in low-income communities throughout the summer; the Fresh Fruit and Vegetable Program, providing fresh fruits and vegetables as school snacks; and the Farm to School Grant Program, providing opportunities for schools to improve their access to local foods.¹¹

The HHFKA also strengthened a requirement for schools participating in the NSLP and/or the SBP to develop wellness policies.¹⁷ School Wellness Policies are individualized for a school’s specific needs, should include specific nutrition and physical activity goals and should be created by the school community with a school representative leading the group who has the authority to assure school compliance. A review of the effect of school wellness policies shortly after implementation of the HHFKA found that schools were “largely successful” in the implementation of policy changes consistent with the HHFKA.¹⁸

The Supplemental Nutrition Assistance Program also known as SNAP, and its educational component, SNAP-Ed are national programs of the USDA that assist food insecure children and their families. SNAP, created in 1975, was updated October 2021 for the first time since its inception by increasing the amount of the SNAP benefit an individual receives, with a goal to increase the possibility for participants to achieve a healthy diet. The Thrifty Food Plan is used for SNAP benefits and is a food plan that estimates the cost of “a nutritious, practical, cost-effective diet prepared at home for a family of four.”¹⁹

SNAP-Ed partners with state and local organizations to provide evidence-based nutrition education and obesity prevention programs for those who are eligible for SNAP benefits. In addition to programing, SNAP-Ed also promotes healthy eating and physical activity through social marketing and working towards policy, systems and environmental changes. (PSE) PSE are interventions that work to impact the economic, social, or physical environment with a goal to improve a community’s health.²⁰

The Expanded Food and Nutrition Program (EFNEP) was started in 1969 as the first national nutrition education program for low income populations. This community outreach program is funded by the USDA and the National Institute of Food and Agriculture (NIFA) and managed by Land Grant Universities. (LGU’s) LGU’s are located in the District of Columbia and all US states and territories and includes Cooperative Extension. Cooperative Extension is the outreach arm of the LGU’s. Many LGU’s use paraprofessional staff in Cooperative Extension to implement EFNEP programming to adults and youth in a variety of settings including schools.

Both EFNEP and SNAP-Ed report success in their programming. In 2021, EFNEP educators reported working directly with close to 150,000 youth and 40,000 adults²¹with outcomes including improvement in their diets and nutrition practices and an increase in their physical activity levels.²² SNAP-Ed has a larger reach and in some states, SNAP-Ed, like EFNEP, is managed by their LGU’s. In 2019, SNAP-Ed LGU educators reported providing direct education to 1.7 million people, with nearly one-half of all participating in SNAP-Ed as children. Many outcomes were reported including decreasing consumption of sugar-sweetened beverages and increasing physical activity and leisure sport through direct education. Thousands of PSE changes related to nutrition and physical activity were also reported.²³

Senior Nutrition Sites and Community Centers

In addition to implementing programming in early care sites and schools, SNAP-ED educators also implement programming in the community in settings such as Senior Nutrition sites and community centers. SNAP-Ed programming for older adults covers topics including nutrition and physical activity with educational content that is geared specifically to this population. A majority of older adults who attend SNAP-Ed educational programs have increased nutrition knowledge²⁴ and research has found that the programming significantly influences their ability to overcome barriers to access, shop for and prepare food.²⁵

The Commodity Supplemental Food Program (CSFP) provides supplemental nutritious USDA foods and nutrition education to low-income adults over the age of 60. Under the USDA, states administer the CSFP through various agencies such as health, social services, education or agriculture departments, storing and distributing the food to local agencies. The local agencies determine participant eligibility, distribute the food and coordinate the required nutrition education. Nutrition education is provided through a contract with the local agency. Another USDA program specifically geared towards older adults is the Seniors Farmers’ Market Nutrition Program. (SFMNP) For low-income seniors, the SFMNP provides coupons that can be used to acquire eligible foods including locally grown fruits, vegetables, herbs and honey at farmers’ markets, community supported agriculture (CSA) programs, and roadside stands. These coupons are also available through the WIC program for young families.

As a result of the 2006 Reauthorization of the Older Americans Act, nutrition education that is geared towards healthful choices and encourages physical activity is required at congregate meal sites such as Senior Nutrition sites and community centers throughout the country.²⁶ This education requirement is often fulfilled by educators who are Registered Dietitians (RDs) from organizations such as the Department of Family and Consumer (or Community Health) Sciences (FCS) from Cooperative Extension and/or RDs who are employed by local grocery stores. These educators generally provide monthly or quarterly sessions on topics including fat or sodium in the diet, reading food labels, or healthful eating on a budget. The ability to assess behavior change when providing nutrition education to older adults in a congregate meal setting can be a challenge and is not frequently attempted. Some results have indicated that use of creative educational displays can be an effective tool in increasing knowledge of specific health-related topics²⁷ and delivery of a nutrition curriculum in several consecutive weeks can lead to an increase in knowledge and behavior regarding reducing intake of fat and increasing fruits and vegetables.²⁸

Worksites

In the same manner that early care sites and schools are ideal settings for the implementation of obesity prevention programming for children, worksites are ideal settings to promote wellness for adults. Worksites are encouraged to promote a healthy work environment through support of healthy eating and activity. Some workplaces offer worksite wellness programs through worksite wellness policies and/or they are offered through employee benefits.

The CDC offers employers ways to improve their workplace environment to work towards employee wellness. Suggestions include increasing physical activity opportunities by adding walking paths and supporting gym access on- or off-site. They can also encourage walking meetings, walking clubs or competitions, and offer incentives to encourage physical activity. Those in charge of workplace cafeterias can consider if offerings are providing healthy food and beverage options for employees.²⁹

Worksite wellness programs are also offered on the state level. For example, the State of New Jersey Department of Health has created a Working Well Toolkit, The toolkit provides examples of evidence-based best practices to work towards optimal productivity and decrease absenteeism and staff turnover.³⁰

The success of worksite wellness interventions has been examined by researchers, including worksites with specific settings. The healthcare work setting is associated with a higher prevalence of obesity due to long work hours, shift work and work-related stress. A recent systematic review of wellness interventions for healthcare workers found that a majority of participants reported improvement in weight with all methods of intervention delivery including via phone, internet or face to face. They also found improvement in weight-related outcomes occurred when the intervention was provided by a trained professional.³¹

Another systematic review looked at the availability and effectiveness of wellness interventions for the low-income working population in the US. Low-wage workers in the US who are in positions such as food preparation and childcare make up a higher incidence of such positions than in 31 other developed countries, and have a higher risk of chronic disease.³² The review determined that the availability of wellness programs is limited at this time and much more needs to be done to develop and implement health promotion programming that is specific to and accessible to this population.

Worksite wellness programs for the general population have also been reviewed for their impact on participants’ body composition³³ (eval of work well-US) and their return on investment (return on invest) for employers. Although there were inconsistencies in 23 studies reviewed for body composition impacts after participating in wellness programs, 13 studies reported results including significant changes in body composition such as decreases in BMI, body fat percentage and waist circumference. These changes were reported in interventions that were associated with longer periods of implementation, in those that included an interactive component for participants and for those that used the client-centered counseling style known as motivational interviewing.³³

Employees with health issues, in particular those with noncommunicable diseases such as diabetes and heart disease, can result in high costs for employers in the form of absenteeism and employer-provided health insurance. A systematic review examining the potential return on investment of workplace wellness programs did not find any evidence in the studies reviewed to indicate that they were beneficial in providing improvement in the health of those studied and thus leading to a decrease in costs for employers. The authors of this review also concluded that more robust studies in this area are needed.³⁴

Community Interventions in the Broader Community

Government-Based Guidance for Obesity Prevention Interventions

The obesity pandemic has resulted in a plethora of health focused interventions that are available in communities across the country for children, adolescents, and adults of all ages. Guidance for designing interventions that meet national objectives are provided from government-based entities such as the CDC, evidence-based reports such as the Dietary Guidelines for Americans (DGA) and large-scale initiatives such as Healthy People 2030. The DGA 2020-2025 is “designed for policymakers and nutrition and health professionals” and assists these groups and others on the state and local level to create associated policies and develop educational programming for the public.³⁵ (Please see a review of the DGA in Chapter 4.)

Healthy People 2030 is developed under the direction of the US Department of Health and Human Services, within their Office of Disease Prevention and Health Promotion. Healthy People’s Mission is “To promote, strengthen, and evaluate the nation’s efforts to improve the health and well-being of all people.”³⁶ To attain the goals of their Mission, Healthy People 2030 determines objectives that touch on every aspect of health and well-being including 358 measurable objectives under the following headings: health conditions; health behaviors; populations; settings and systems; and social determinants of health. Within each heading, there are topics with more specific goals and objectives, many of which can be cross referenced. For example, in the topic “Overweight and Obesity”, the goal is to “Reduce overweight and obesity by helping people eat healthy and get physically active,” and the objectives under this heading include Diabetes and Nutrition and Healthy Eating.³⁷ These goals and objectives help to drive the work that is planned and implemented regarding health and wellness nationwide.

The White House Conference on Hunger, Nutrition and Health, hosted by the Biden-Harris Administration and held in September of 2022, was the first conference of its kind in over 50 years. Participants of the conference included “elected officials; advocates and activists; and leaders of business, faith and philanthropy” from across the US³⁸ and resulted in the Biden-Harris Administration National Strategy on Hunger, Nutrition and Health. The “bold goal” of this strategy is to end hunger and increase healthy eating and physical activity by 2030, thereby decreasing the incidence of diet-related chronic diseases for all Americans. The strategy encompasses all individuals including those living in urban, suburban, rural and Tribal communities and territories and focuses on issues of equity, access and disparities.³⁹

To meet the above goals, the National Strategy identifies the following five pillars:

• Improve Food Access and Affordability
• Integrate Nutrition and Health
• Empower All Consumers to Make and Have Access to Healthy Choices
• Support Physical Activity for All
• Enhance Nutrition and Food Security Research

The strategy recognizes that the federal government cannot meet these ambitious goals by 2030 alone or without resources, includes Calls to Action from all potential partners throughout the strategy and includes more than $8 billion in new commitments to do so. These commitments from the private and public sector include in-kind donations to community-based organizations to work towards completing the work of the strategy including community interventions from the start-ups Everytable and Wellory and the nonprofit organizations Action for Healthy Kids, Hunger Free Oklahoma and many more.³⁹

Non-Government Organizations and Obesity Prevention Interventions

Many non-government organizations (NGO) have also been created, both on the national and local level, to assist in addressing the issues that lead to overweight and obesity. Share Our Strength was started in 1984 as a response to the famine in Ethiopia, and although their work continues to address national and international disaster relief efforts,⁴⁰ Share Our Strength is possibly best known for its national campaign to end childhood hunger, No Kid Hungry,⁴¹ and its community cooking program Cooking Matters. Cooking Matters (CM) works to “make eating healthier fast for families everywhere” with their signature six-week cooking classes for small groups of children to older adults.⁴² All classes include a nutrition education component and include an eating on a budget focus.

The impact of CM on children ages 9-13 from 2012-2017 was assessed in a large study with over 18,000 children. Outcomes indicated that from pre- to post-survey, the children studied had an improvement in both their attitudes towards healthy foods and self-efficacy for healthy eating and cooking.⁴³ CM also reports that in 2015, a national study of CM participants indicated “83% of parents and caregivers report readiness to adopt healthier, budget-friendly shopping techniques.”⁴⁴ In addition to cooking classes, CM also offers grocery store tours, online professional development for caregivers and for those unable to join in-person classes, the CM website offers videos and healthy recipes.

The Food Trust is an NGO that was founded in 1992 in the Philadelphia, PA area, but now works to “ensure delicious nutritious food for all” nationwide by working with neighborhoods, institutions, retailers, farmers and policymakers.⁴⁵ The Food Trust has a community centered approach in all they endeavor to do and are perhaps best known for their Healthy Corner Store Initiative. This initiative works with small independently owned food stores, providing them with training and equipment to be able to purchase and store more produce and other healthful foods and marketing materials to promote the new items.⁴⁶

Including the community in the planning process where an organization is seeking to implement an initiative is often a preliminary step that can assist in working towards a successful project. For example, focus groups and community surveys are often employed. In 2016, the Food Trust and Stanford University used a Photovoice technique in Camden, NJ whereby participants documented visits to corner stores with “geo-located photos and audio narratives” which helped to identify issues at, and potential solutions for, the stores involved.⁴⁷ The Photovoice technique offers an inclusive method for communities to engage residents who will ultimately benefit from the intervention.

Strategic placement of overweight and obesity prevention interventions in communities where food is found, such as in corner stores or at farmers’ markets, is ideal for providing teaching opportunities. Education topics can include many aspects of the importance of good nutrition as well as the ability to feature foods that are healthful choices and how to prepare them. Community and school gardens have been successful in providing these opportunities and others including incorporating physical activity and mindfulness while gardening.⁴⁸ In a large garden project in South Dakota that was part of the CDC’s High Obesity Program, the South Dakota State University Cooperative Extension worked with communities to plant thirteen gardens. The project included nutrition and physical activity lessons at the garden sites, grew an average of 138 pounds of produce from each garden and were able to donate much of the produce to food pantries. Through collaborations with community members, community organizations, city and tribal organizations and schools, this garden project increased their sustainability potential.⁴⁸ Determining routes to sustainability is often an issue with maintaining community and school gardens.

Summary

From early care sites to older adult settings and many places in between, there are community nutrition and physical activity interventions being planned and taking place towards combatting overweight and obesity in the United States every day. Many taxpayer, donated, federal and NGO dollars are being allocated for this purpose with some progress slowly being realized over the past several years. However, much more needs to be done, especially for our youth, for those who are food insecure and for those who have high rates of obesity. Many with the greatest needs have not received equitable interventions or resources due to poverty, racism, and other social and economic factors.¹¹

There is a renewed promise of progress towards these issues with the substantial plan from the Biden-Harris Administration National Strategy on Hunger, Nutrition and Health. This strategy will support the use of a systems approach, recommended in the TFAH State of Obesity Report 2022. This type of approach is necessary for communities to support healthy lifestyles for people across the lifespan and where they are because “the health of individuals and families are impacted by the communities in which they are born, live, work, learn, play, worship, and age.”¹¹ When a host of players from all sectors of society work in tandem towards a common goal, the way forward and its results are packed with potential.

Resources

Early Head Start and Head Start

Child and Adult Care Food Program (CACFP)

National School Lunch Program (NSLP)

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

SNAP-Ed

Expanded Food and Nutrition Program

Healthy People 2030

Biden-Harris Administration National Strategy on Hunger, Nutrition and Health

References

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