Alabama Obesity Task Force - Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama

 
Alabama Obesity
        Task Force
      Strategic Plan for the
     Prevention and Control
       of Overweight and
       Obesity in Alabama

Alabama Depar tment of Public Health
TABLE OF CONTENTS

Letter from the State Health Officer ........1               Alabama State Obesity Task Force .........19
Executive Summary..................................2            History ..............................................20
Overview of the obesity epidemic.............3                  General guiding principles
   What is obesity?...................................4         of the task force .................................20
     Body Mass Index..............................4               Multifaceted approach
     Over-fat............................................4        guidelines .......................................20
     Waist circumferences ........................5               Evidenced-based
   Obesity trends......................................5          approaches that work .....................22
   Influencing factors ...............................6      Alabama’s State Plan: ..............................23
     Nutrition..........................................6       General comments .............................24
     Physical activity................................7         How to use the state obesity plan ......24
   General consequences ..........................7             Six working groups:
     Health concerns ...............................7           Perspectives in Alabama .....................25
     Economic .........................................9          Nutrition subcommittee.................25
Alabama specifics....................................11           Physical activity
   Alabama trends (BRFSS) ...................12                   subcommittee.................................26
     Alabama adults...............................12              Data subcommittee ........................29
     Alabama youth/ children ................12                   Youth and family
     Alabama racial and                                           subcommittee.................................31
     socioeconomic influences ...............13                   Community subcommittee.............32
   Influencing factors ............................14             Healthcare subcommittee ...............34
     Nutrition........................................14        Additional areas of intervention .........34
     Physical activity..............................14            Media and social marketing............34
     Attitudes .......................................14          Research .........................................35
   General Consequences .......................15                 Funding concerns...........................35
     Health ............................................15   Resources for Implementing
     Economic burden...........................16            The Plan ...............................................36
Healthy Alabama 2010...........................17            References ..............................................45

                        Alabama Department of Public Health
LETTER FROM THE STATE HEALTH OFFICER

T
                 he goal of the State Obesity               sis will be placed on a healthy relationship
                 Task Force was to develop and              with food, a healthy body weight, and a phys-
                 implement a comprehensive,                 ically active lifestyle. Approaches include
                 realistic state plan which will            learning to select appropriate amounts and
                 reduce the worsening obesity               types of foods as well as learning personal
                 epidemic in Alabama. The                   coping mechanisms to replace comfort eating.
plan was not to change approaches already in                There is a consensus that people know they
progress, but rather to create a uniform                    “should eat right”, but I am less convinced
approach to reduce obesity. The Alabama                     that people know what actually is right or
State Obesity Plan provides goals and objec-                how to do it.
tives to follow at various social-ecological lev-               The approach in this report is to address
els. The plan provides various approaches to                good nutrition and physical activity through-
address the impact of obesity on Alabama’s                  out the lifecycle. Breastfeeding support is the
citizens including education and awareness,                 logical place to start, as breastfeeding decreas-
lifestyle and behavioral choices, community-                es the chances of the child becoming over-
based environmental strategies, school and                  weight while assisting the mother to return to
worksite improvements, and policy develop-                  a pre-pregnancy weight. The importance of
ment or changes. This plan does not address                 the school day for our children and the work
pharmacological or medical interventions,                   place setting for adults cannot be understated.
however, these are also appropriate for certain             The structured school/ work setting can help
individuals based on established medical cri-               people to make good decisions as long as the
teria. It is our hope that the plan is used                 positive options are there. Communities
statewide as a reference for selecting                      developing walkable areas for all citizens,
approaches to implement. It can be benefi-                  resulting in physical activity opportunities
cial in setting formal goals, such as in a cor-             that are readily available, can happen.
porate business plan, as well as in informal                    Data will be a key in evaluation and for
settings, such as a community project.                      future documentation. It will be helpful to
    The various levels of influence, as noted in            have standardized health data at the county or
the adaptation of a social-ecological model,                town level.
are important since the question of whether                     To make this truly a plan for the entire
obesity is a personal concern versus a public               state, new partners are encouraged to join.
health concern exists. I propose it is both.                With all of us working together, we can make
Obesity is a public health issue because an                 a difference.
overwhelming majority (80 percent) of per-
sons who are obese have additional health                   “Alabama, together one choice, one step, and
problems. The individual has the ultimate                   one life at a time!”
responsibility in making wise choices, but at
the same time the environment must support,
encourage, and even reinforce personal deci-
sion-making processes.
    In addressing weight concerns, an empha-
                              Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama   1
EXECUTIVE SUMMARY

    In the United States, obesity has risen at                      “Being overweight or obese is a very com-
an epidemic rate during the past 20 years. In                   plex issue with many different contributing
2003, 15 states had obesity prevalence rates                    factors. This plan must be passionate, cre-
of 15 to 19 percent; 31 states had rates of 20                  ative, and innovative with solutions that do
to 24 percent; and four states had rates more                   not simply mimic other states.”
than 25 percent. Alabama was one of the four
states.                                                             “The severity of obesity in Alabama makes
                                                                our challenge even greater. Media campaigns
    To develop a multifacet approach, a                         and public education are important but will
statewide task force was organized in 2004.                     not be the only or best solution to a problem
The task force included representatives from                    of this magnitude.”
state and local governments, medical profes-
sionals, academia and research, industry, com-                     “Task force members must be willing to
munity, and citizen representatives. This                       challenge current ideas and solutions. We
report is the result of their work.                             must "think outside the box" when develop-
                                                                ing approaches to this problem. Our
    The Alabama Obesity State Plan provides                     approach needs to combine prevention, inter-
a statewide focus for reducing and preventing                   vention, evaluation, and research. This plan
obesity through healthy lifestyles that empha-                  must have realistic, workable solutions.”
size balanced eating patterns and adequate
physical activity. The strategies outlined in                      The format of this report includes individ-
the plan are targeted for all age groups, races,                ual sections on obesity trends in the nation
and socioeconomic classes. This plan will not                   and in Alabama, specific goals and actions
eliminate existing efforts, but does encourage                  steps for each subcommittee, and tools or ref-
statewide collaboration.                                        erences to assist implementing the plan at all
                                                                levels.
   General statements and opinions from the
task force set the tone for the overall goals
and measurable objectives. These statements
included:

2   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
Overview of the
       Obesity
      Epidemic
Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama   3
OVERVIEW OF THE OBESITY EPIDEMIC

WHAT IS OBESITY?                                                 Below is an example of calculating a BMI
                                                                 using the English system and in the metric
Body Mass Index                                                  system.
    Obesity is defined as an excessively high                        • English Formula:
amount of body fat or adipose tissue in rela-
tion to lean body mass. Body Mass Index                             BMI=               (Weight in Pounds)
                                                                                                                 X 703
(BMI) is a common measure expressing the                                   (Height in Inches X Height in Inches)
relationship (or ratio) of weight-to-height. It
is a mathematical formula in which a person's                               (220)
body weight in kilograms is divided by the                                           x 703= 27.5
                                                                          (75 X 75)
square of his or her height in meters squared
                                                                 A person who weighs 220 pounds and is 6
(wt/(ht)2. The BMI is more highly correlated
                                                                 feet 3 inches tall has a BMI of 27.5.
with body fat than any other indicator of
height and weight. Individuals with a BMI
of 25 to 29.9 are considered overweight and                         •     Metric Formula:
are approximately 20 pounds above appropri-                                      Weight in Kilograms
                                                                          BMI=
ate weight for height. Individuals with a                                        (Height in Meters)2
BMI of 30 or more are considered obese and
are 30 or more pounds over appropriate                                      99.79
                                                                                      = 27.5
weight for height. For adults over 20 years                             1.905 X 1.905
old, BMI falls into one of these categories:
               Adult (21 and over)                               A person who weighs 99.79 kilograms and is
                                                                 1.905 meters tall has a BMI of 27.5.
    BMI                            Weight Status
    Below 18.5                     Underweight                   Use of BMI for Children
    18.5 – 24.9                    Normal
    25.0 – 29.9                    Overweight                        The terms obese, overweight and at risk
                                                                 for overweight are defined differently in pedi-
    30.0 and Above                 Obese
                                                                 atric populations than in adults (see chart
                                                                 below). Body Mass Index (BMI) is the pri-
    Children and Adolescent (2-20)
                                                                 mary measure utilized to define weight stats
    BMI                      Weight Status                       in both adults and children. BMI is calculat-
    Underweight
lation changes with age. Because of these dif-             important in the disease process than subcu-
ferences between adult and children’s BMIs,                taneous fat, which is just under the skin.
the BMI for the pediatric population must be               Abdominal fat cells appear to produce certain
plotted on the CDC growth charts enabling                  compounds that may influence cholesterol
on to determine BMI-for-age percentiles                    and glucose metabolism. Men are at risk who
(www.edc.gov/growthcharts). The chart,                     have a waist measurement greater than 40
Children & Adolescents, summarizes the cat-                inches (102 cm). Women who have a waist
egories by BMI and percentages in children.                measurement greater than 35 inches (88 cm)
                                                           are at risk. The waist size appears to be an
                                                           independent risk predictor when BMI is at
BMI Limitations                                                         Obesity Trends*
    Body Mass Index (BMI) reflects body                              Among U.S. and Adulth
composition and correlates well with body                            BRFSS, 1991, 1996, 2003
                                                            *BMI≥30, or about 30 lbs overweight for 5’4” person
fat; however, it has limitations. A very mus-
cular person may be in the overweight BMI                                          1991
category. For example, professional athletes
may be very lean and muscular, with very lit-
tle body fat, yet due to the weight of the
increased muscle, they may weigh more than
others of the same height. This would need
to be considered in reviewing their BMI.
While they may qualify as "overweight" due
to their large muscle mass, they are not neces-
                                                                                   1996
sarily "over fat," regardless of BMI.
    It is possible for a person who is in an
appropriate BMI weight range to be “over
fat”. By using a skinfold or fat analysizer, the
percent of body fat can be determined.

Waist circumferences
    The amount of body fat (or adiposity)
includes concern for both the distribution of                                      2003
fat throughout the body and the size of the
adipose tissue deposits. The waist size is an
additional, independent risk factor for certain
diseases and can be used in conjunction with
the BMI. Waist measurements reflect evi-
dence that excess visceral fat - surrounding
the abdominal organs - increases the chance
of heart disease or diabetes. Research indi-
                                                                   No Data         < 10%      10% - 14%
cates that visceral fat (waist size) is more
                                                                 15% - 19%      20% - 24%          25%

                              Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 5
25- 34.9                                                        obesity. The array of associated physical dis-
    NOTE: If a person has short stature (under                  orders and emotional problems that often
5 feet in height) or has a BMI of 35 or above,                  accompany obesity can persist, and frequently
waist circumference standards used for the gen-                 worsen, throughout life. Moreover, the prob-
eral population may not apply.                                  ability of adult obesity increases as overweight
                                                                children age: 50 percent of children who are
                                                                overweight at age six will become overweight
OBESITY TRENDS                                                  adults, by adolescence, the probability esca-
                                                                lates to 80 percent. If one parent is over-
    Obesity is occurring worldwide as well as                   weight or obese, the child has an 80 percent
nationally. The words “pandemic” and “epi-                      chance of being overweight or obese. Adults
demic” have been used to describe the dra-                      who were overweight as children are at
matic upward trends seen in adults and chil-                    increased risk for poor health for longer peri-
dren. According to the World Health                             ods than adults who were not overweight as
Organization, the United States has the great-                  children.
est incidence of overweight and obesity in the                      Disparities in overweight and obesity
world. The prevalence of obesity has                            prevalence exist in segments of the population
increased steadily and is at epidemic levels.                   based on race and ethnicity, gender, age, and
Results from the 1999–2002 National Health                      socioeconomic status. For example, over-
and Nutrition Examination Survey                                weight and obesity are particularly common
(NHANES), using measured heights and                            among minority groups and those with a
weights, indicate that an estimated 65 percent                  lower family income. The prevalence of over-
of U.S. adults are either overweight or obese.                  weight and obesity is higher in women of
The Centers for Disease Control (CDC) and                       minority populations than in caucasian
Prevention report that Alabama is ranked first                  women. Among men, Mexican Americans
in terms of number of adults with overweight                    have a higher prevalence of overweight and
and obesity.                                                    obesity than caucasians or African Americans.
                                                                For non-Hispanic men, the prevalence of
    Adults are not the only ones with excessive                 overweight and obesity among Caucasians is
weight. Childhood obesity has become the                        slightly greater than among African
most prevalent pediatric nutritional problem                    Americans.
in the United States. Results from the                              Among school aged children, there is a
1999–2002 National Health and Nutrition                         higher occurence of obesity in African
Examination Survey (NHANES), using meas-                        American, Native American, Puerto Rican,
ured heights and weights, indicate that an                      Mexicans, and Native Hawaiins. Data from
estimated 16 percent of children and adoles-                    CDC shows African American and Hispanic
cents ages six to nineteen years are over-                      Children are at 21.5% as compared to 12.3%
weight. The prevalence rate has been rising                     of Caucasians children.
steadily in all age groups, with overweight
being seen at younger ages. Excess weight in
childhood is frequently a precursor to adult                    INFLUENCING OBESITY

6   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
FACTORS                                                    ing, whether it is out of boredom, seeking
                                                           comfort, relieving stress, or celebrating, can
    Obesity is a complex issue. Body weight is             add extra, unexpected calories.
the result of genes, metabolism, behavior,                     An emphasis is being placed on family
environment, culture, and socioeconomic sta-               meals at home. Children eating more than
tus.                                                       three (3) meals per week with the family were
    Specific rare hereditary diseases may                  less likely to skip breakfast. The children also
increase the risk of obesity. In addition, there           had better consumption of fruits, vegetables,
seems to be a general tendency for obesity to              and diary foods. Family meals frequency had
run in some families, though the reason for                a strong positive association with energy
this is not well understood. Behavior and                  intake, percentage of calories from protein,
environment play a large role influencing                  calcium, iron, vitamins A, C, E, B6, folate,
people to be overweight and obese. However,                and fiber.
generally and very simplistically speaking obe-
sity is a result of an energy imbalance. This              Physical activity
means most Americans are eating too many                       The incidence of overweight and at risk of
calories and not getting enough physical                   overweight is directly linked to lack of physi-
activity.                                                  cal activity and increase in inactivity, such as
                                                           viewing television more than two hours per
Nutrition                                                  day. Our society has become very sedentary.
    The American eating pattern has been                   Approximately 43 percent of adolescents
studied to identify reasons causing the obesity            watch more than two hours of television each
epidemic. The studies indicate that                        day. Girls are less active than boys are and
Americans have lost perception of the stan-                become even less active as they move through
dard serving size. Serving sizes started grow-             adolescence. Numerous health-related organ-
ing in 1970, rose sharply in the 1980’s, and               izations have recommended increased physical
continued to increase in the 1990’s. It was                activity in order to decrease overweight and
during this time Americans lost the percep-                the associated risk factors. The American
tion of a serving size. According to the                   Heart Association, the Institute of Medicine,
American Diabetic Association, most                        the United States Department of Health and
Americans overestimate how much food                       Human Services, the U. S. Surgeon General,
makes up one serving.                                      Action for Healthy Kids, Centers for Disease
    Americans are also eating away from home               Control and Prevention, and the Robert
more now than in the past. The American                    Wood Johnson Foundation, are examples of
Cancer Society reports that servings in restau-            health-related agencies calling for increased
rants are approximately two and a half times               physical activity for children.
what the average female needs. When large                      There are numerous reports that evaluate
portion sizes are coupled with the types of                the relationship between academic perform-
foods we consume, high fat, high sugar, high               ance and health behavior. Action for Healthy
calorie, weight gain is not a surprise.                    Kids reports that in school districts across the
    Eating for reasons not related to hunger               United States, administrators, teachers, and
also plays an important role. Emotional eat-               researchers are demonstrating that proper

                              Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 7
nutrition and physical activity are linked to                    •   Infections following wounds
academic achievement, self-esteem, mental                        •   Infertility
health, and improved school attendance.                          •   Liver Disease
                                                                 •   Low Back Pain
                                                                 •   Obstetric and Gynecologic Complications
GENERAL                                                          •   Pain
CONSEQUENCES                                                     •   Severe acute biliary and alcoholic pancre-
                                                                     atitis
Health concerns                                                  •   Sleep apnea
    Overweight and obesity are estimated to                      •   Stroke
be second only to smoking as preventable                         •   Surgical complications
causes of death. The proportion of deaths                        •   Type 2 Diabetes (Non Insulin Dependant
where obesity is a major contributing factor                         Diabetes Mellitus)
will grow with continued increase in obesity                     •   Urinary Stress Incontinence
prevalence. Life expectancy is predicted to
fall in coming years because of obesity, a star-                Of these health concerns, the chart below lists
tling shift in a long-running trend toward                      the leading causes of death in 2002 according
longer lives. It is estimated that within 50                    to the CDC Division of Vital Statistics. These
years, obesity will shorten the average life                    apply to both male and female adults.
span of 77.6 years by at least two to five
                                                                       2002 Leading Causes of Death
years; more than the impact of cancer or
heart disease.                                                    Heart Disease . . . . . . . . . . . . . . . . .28.5%
                                                                  Malignant Neoplasm (Cancer) . . . .22.8%
                                                                  Cerebrovascular Diseases (Stroke) . . .6.7%
      Obesity is linked to many health
              diseases, such as:                                  Chronic Lower Respiratory Disease . . .5.1%
•   Arthritis - Osteoarthritis of knee and hip,                   Accidents (Unintentional) . . . . . . . . .4.4%
    Rheumatoid Arthritis                                          Diabetes Melitus . . . . . . . . . . . . . . . .3.0%
•   Birth Defects                                                 Influenza/Pneumonia . . . . . . . . . . . .2.7%
•   Cancers - Breast Cancer, Colorectal
                                                                  Alzheimer’s . . . . . . . . . . . . . . . . . . . .2.4%
    Cancer, Esophagus and Gastric Cancer,
    Endometrial Cancer, Renal Cell Cancer
                                                                    Obesity and overweight substantially
•   Cardiovascular disease
•   Carpal Tunnel Syndrome                                      increase the risk of morbidity from hyperten-
•   Daytime Sleepiness                                          sion; dyslipidemia; type 2 diabetes; coronary
•   Deep Vein Thrombosis                                        heart disease; stroke; gallbladder disease;
•   End Stage Renal Disease                                     osteoarthritis; sleep apnea and respiratory
•   Gallbladder Disease                                         problems; and endometrial, breast, prostate,
•   Gout                                                        and colon cancers. Higher body weights are
•   Heart Disorders                                             also associated with increases in all-cause
•   Hypertension                                                mortality. Significant health problems occur
•   Impaired immune response                                    in the pediatric age group as well as the adult
•   Impaired respiratory function                               population.

8   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
Obesity Related Morbidities                          death in the United States. They account for
 Cardiovascular                                            more than 40 percent of all deaths. About
 Accelerated atherosclerosis                               950,000 Americans die of cardiovascular dis-
 Dyslipidemia (increased triglycerides, low                ease each year, which amounts to one death
  HDL cholesterol level, increased LDL                     every 33 seconds. It is estimated that 61 mil-
  cholesterol level)                                       lion Americans, almost one-fourth of the
 Hypertension                                              population, have some form of cardiovascular
 Increased left ventricular mass                           disease. High blood pressure is a major risk
 Endocrinologic                                            factor for heart disease and the chief risk fac-
 Hyperinsulinemia                                          tor for stroke and heart failure, and also can
 Insulin resistance                                        lead to kidney damage. It affects about 50
 Early puberty (accelerated linear growth                  million Americans–one in four adults. Studies
  and bone age)                                            show that the risk of death from heart disease
 Polycystic ovaries, dysmenorrhea                          and stroke begins to rise at blood pressures as
 Respiratory                                               low as 115 over 75, and that it doubles for
 Hypoventilation (Pickwickian syndrome)                    each 20 over 10 millimeters of mercury (mm
 More frequent respiratory infections                      Hg) increase. So, the harm starts long before
 Sleep apnea                                               people get treatment.
 Orthopedic                                                “Unless prevention steps are taken, stiffness and
 Coxa vara                                                 other damage to arteries worsen with age and
 Slipped capital femoral epiphyses                         make high blood pressure more and more diffi-
 Blount's disease                                          cult to treat. The new pre-hypertension category
 Legg-Calve-Perthes disease                                reflects this risk and, we hope, will prompt peo-
                                                           ple to take preventive action early” said NHLBI
    Obesity is linked to cardiovascular disease
                                                           Director Dr. Claude Lenfant.
and type 2 diabetes through the promotion of
                                                           Cancers
insulin resistance and other associated physio-
                                                               Fat cells are not static deposits. Visceral
logical abnormalities, including dyslipidemia,
                                                           fat is metabolically active and increased vis-
elevated blood pressure, and increased left
                                                           ceral fat is linked to certain cancers. Obesity
ventricular mass. Overweight and insulin
                                                           is strongly linked to cancer of the uterine lin-
resistance have been linked to the early devel-
                                                           ing or endometrium. An overweight woman
opment of atheromata in young adults inde-
                                                           has twice the risk of developing that cancer as
pendent of other cardiovascular risk factors.
                                                           a lean one; once she becomes obese the risk
Pulmonary, skeletal, dermatologic, immuno-
                                                           rises as much as three and a half (3.5) to five
logic, and endocrinologic systems display
                                                           (5) fold. A person who is obese has up to
obesity-related morbidities. These apply to
                                                           triple the risk of kidney cancer and of
male and female as noted in the chart above.
                                                           esophageal cancer as does someone in an
                                                           appropriate body weight range. Overweight
Cardiovascular Health
                                                           and obese men are 50 percent as likely as lean
    Heart disease and stroke are the principal
                                                           men to get colon cancer; for women the extra
components of cardiovascular disease and are
                                                           risk is 20 to 50 percent. Fat is linked to
listed as the first and third leading causes of

                             Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama   9
breast cancer in postmenopausal women and                       an increased risk for developing type 2 dia-
increases the risk of the disease by 30 percent                 betes during both childhood and later in life.
among the overweight and 50 percent among                       There is a reported association between obesi-
the obese. Prostate cancer is more common                       ty and type 2 diabetes, sugared beverage con-
in men who have BMI of 35 or higher. In                         sumption, long hours of television viewing,
addition, these men have a 60 percent risk of                   and reduced physical activity.
cancer recurrence within three years or more.
This is twice the rate seen in men at the                       Economics
appropriate weight.                                                 Obesity is associated with increased dis-
                                                                ability, decreased optimal health, increased
Diabetes                                                        health care use, and increased mortality, all of
    During the past ten years, the incidence of                 which translate into increased health care
diabetes has nearly tripled. Overweight and                     cost. The direct and indirect costs of obesity
obesity are significant risk factors for diabetes.              care for the nearly 119 million American
The majority of adults diagnosed with dia-                      adults, 65 percent of the population, who are
betes in the United States are either over-                     currently overweight or obese is more than
weight (85.2 percent) or obese (54.8 percent).                  $117 billion per year. This is an increase
Persons who have a body mass index (BMI)                        from previous studies. Taxpayers finance
of more than 30 are 10 times more likely to                     about half of these costs through Medicare
develop the illness; with a BMI above 35 for                    and Medicaid. "Obesity has become a crucial
10 years, the risk increases to 80 times com-                   health problem for our nation, and these
pared to a person of average weight.                            findings show that the medical costs alone
Projections are that 40 to 50 million United                    reflect the significance of the challenge," said
States residents could develop diabetes by                      previous Health and Human Services
2050.                                                           Secretary Tommy G. Thompson.
    Type 2 diabetes in school children is a new                     Poor health is an economic burden on the
phenomenon. Twenty years ago, it was rare                       nation and costs millions of dollars in terms
for an adolescent or child to be diagnosed                      of diminished health and productivity. The
with type 2 diabetes. However, during the                       figures confirm earlier findings that obesity
last 20 years, childhood diabetes has increased                 accounts for a significant, and preventable,
10-fold. In several clinic-based studies, the                   portion of the nation's medical bill.
percentage of children with newly diagnosed
diabetes has risen from
Alabama
                       Specifics

Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama   11
ALABAMA SPECIFICS

ALABAMA TRENDS                                                                         Alabama Adult BMI Categories - 2003
    Alabama is currently in an overweight and                                          40
obesity epidemic situation regarding the
health of its citizens. The nonprofit group,                                           35      36.8
                                                                                                                      34.8
Trust for America's Health, named Alabama
                                                                                       30

                                                                   Percent of People
as the “fattest state” in the nation in October
                                                                                                            28.4
2004. Mississippi and West Virginia followed                                           25
in second and third places. Alabama ranked
                                                                                       20
first in adult obesity based on 2003 data,
with 28.4 percent of adults in the obese cate-                                         15
gory.
                                                                                       10
Alabama adults
                                                                                        5
    Sixty-three percent of Alabama adults are
overweight and or obese. Obesity is defined                                             0
as a BMI ≥30 and overweight is a BMI 25 to                                                    ≤ 24.9     25.0 - 29.9   ≥ 30
                                                                                                       Body Mass Index
29.9. Of the 63 percent, 28.4 percent are
obese and 34.8 percent are overweight.
    Overweight and obesity are prevalent and                    of youth were at risk for being overweight
increasing in Alabama. According to the                         with an additional 14 percent already over-
Alabama Behavior Risk Factor Surveillance                       weight, as defined as body mass index at or
System (BRFSS), from 1991 to 2001 obesity                       above the 95th percentile for age.
rates increased 76 percent. The BRFSS eval-                         The Alabama Department of Public
uates weight status in Alabama adults by ask-                   Health (ADPH) and the Alabama State
ing height and weight questions in a random                     Department of Education collected height
digit telephone survey. Questions are devel-                    and weight data on 822 adolescent students
oped by the Centers for Disease Control and                     in six schools from different geographic
Prevention (CDC). In 2003 in Alabama,                           regions in Alabama in 2001. Forty four (44)
approximately 28 percent of adults were                         percent of the evaluated students were at risk
obese, with rates similar for men (27.1 per-                    for overweight or overweight based upon
cent) and women (29.6 percent). In addi-                        body mass index (BMI). In 2002, a study
tion, approximately 35 percent of the adults                    completed by ADPH staff of 1,182 students
were overweight -- considerably more males                      in the second, third, fourth, and fifth grades
(42.9 percent) than females (27.3 percent).                     in six public schools located in Monroe
                                                                County, Alabama found approximately 17
Alabama youth/ children                                         percent were at risk for overweight and 27
   Alabama youth are also overweight. Self-                     percent were overweight. Rates were higher
reported data from the 2003 Youth Risk                          for black students (29.8 percent) than for
Behavior Survey (YRBS) showed 14 percent                        white students (23.6 percent).

12   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
As indicated in the chart below, obesity rates are above 20 percent in all age groups, with the excep-
tion of age 65 and older.
    Age            Neither Overweight                   Overweight                                                                                   Obese
                 nor Obese (BMI≤24.9)                (BMI 25.0-29.9)                                                                             BMI≥30
18-24 %                      53.1                             26.7                                                                                    20.3
      CI                  (45.3-60.9)                      (19.3-34.0)                                                                              14.5-26.0
      n                       124                               49                                                                                      54
25-34 %                      39.8                             31.2                                                                                    29.0
      CI                   35.1-44.6                        26.6-35.7                                                                               24.5-33.5
      n                       208                              148                                                                                     141
35-44 %                      30.3                             36.3                                                                                    33.3
      CI                   26.1-34.5                        31.7-40.9                                                                               28.8-37.9
      n                       190                              187                                                                                     181
45-54 %                      28.9                             37.3                                                                                    33.8
      CI                   24.9-32.9                        32.8-41.9                                                                               29.5-38.1
55-64 %                      29.4                             36.6                                                                                    34.1
      CI                   25.3-33.5                        32.1-41.0                                                                               29.7-38.4
      n                       179                              202                                                                                     199
65+   %                      41.7                             39.4                                                                                    18.9
      CI                   37.7-45.6                        35.4-43.4                                                                               15.7-22.1
      n                       310                              268                                                                                     129

Alabama racial and socioeconomic                           is in 16 counties, 15 of which are in
differences                                                Alabama's economically depressed region.
    Racial and socioeconomic differences in                This area, known as the Black Belt of the
prevalence rates are also evident. In the over-            state, was once known for the dark soil for
weight category, the Hispanic population was               agriculture. Although the region is known for
at 50.3 percent, the White population at 34.7              timber production, rich hunting and fishing,
percent, and the Black population was at 32.4              and Civil Rights history, the term Black Belt,
percent. Obesity was prevalent in 37 percent               has evolved to a reference to the predominate
of African american versus 26.5 percent of                 ethnicity in the area.
Caucasian, and only 14 percent of Hispanics.
                                                                         Estimated Number of People at Risk for Obesity
The prevalence of obesity among persons at                                  among Adults Aged 18 and Over Bases on
                                                                         Distribution by Age, Race, and Sex and Assigned
the lowest income levels (less than $15,000                                    Risk from the BRFSS, Alabama 2000
                                                                                         LAUDERDALE
                                                                                                                     LIMESTONE                         JACKSON

annually) was approximately 32 percent,                                                   COLBERT
                                                                                                                                   MADISON

                                                                                         FRANKLIN         LAWRENCE           MORGAN

compared to a prevalence of almost 25 per-
                                                                                                                                                              DEKALB
                                                                                                                                             MARSHALL

                                                                                      MARION              WINSTON                                                   CHEROKEE
                                                                                                                            CULLMAN
                                                                                                                                                         ETOWAH

cent among persons with annual incomes at                                       LAMAR        FAYETTE
                                                                                                            WALKER
                                                                                                                                       BLOUNT

                                                                                                                                           ST. CLAIR
                                                                                                                                                              CALHOUN

or exceeding $50,000. Obesity occurred in                                                                                  JEFFERSON

                                                                                                                                                  TALLADEGA
                                                                                                                                                                        CLEBURNE

                                                                               PICKENS            TUSCALOOSA                                                    CLAY

approximately 28 percent of adults with less
                                                                                                                                 SHELBY                                  RANDOLPH

                                                                                                                    BIBB
                                                                                    GREENE                                                       COOSA       TALLAPOOSA CHAMBERS
                                                                                                                                 CHILTON

than a high school education, compared to 22                                                      HALE
                                                                                                             PERRY
                                                                                                                                                    ELMORE                         LEE
                                                                           SUMTER                                                AUTAUGA

percent among college graduates.                                                         MARENGO
                                                                                                                   DALLAS                       MONTGOMERY
                                                                                                                                                                     MACON
                                                                                                                                                                                    RUSSELL

                                                                                                                                 LOWNDES                            BULLOCK

    A geographic study of obesity in Alabama                             CHOCTAW                          WILCOX

                                                                                                                                                             PIKE
                                                                                                                                                                               BARBOUR
                                                                                                                                 BUTLER

was completed utilizing BRFSS obesity data                               WASHINGTON
                                                                                         CLARKE

                                                                                                         MONROE
                                                                                                                                           CRENSHAW

                                                                                                                                                                        DALE
                                                                                                                                                                                    HENRY

                                                                                                                     CONECUH                              COFFEE

from 1995 to 2000 combined with US                                                                            ESCAMBIA
                                                                                                                                        COVINGTON
                                                                                                                                                               GENEVA
                                                                                                                                                                                   HOUSTON

Census 2000 data. The geographic distribu-                                 MOBILE

                                                                                             BALDWIN
                                                                                                                                           26.6-31.8%
                                                                                                                                           24.5-26.5%
tion of obesity illustrates the highest burden                                                                                             23.1-24.3%
                                                                                                                                           21.8-23.0%

                            Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama                                                                                13
INFLUENCING FACTORS                                                            is very important in weight control. Despite
                                                                               all the benefits of being physically active,
Nutrition                                                                      most Alabamians are sedentary.
    It is well established that consuming five                                     Alabama was ranked as the tenth worst
or more servings of fruits and vegetables a day                                state in terms of prevalence of no leisure time
and three servings of low fat milk are benefi-                                 physical activity. Twenty-seven percent of
cial in weight control. However, in Alabama                                    Alabama adults reported participating in no
77.4 percent of adults do not eat 5 servings of                                leisure time physical activity.
fruit and vegetables a day. Dietary Behaviors                                      In addition, 60 percent of the population
of Alabama students indicate 85.5 percent of                                   did not meet the national guidelines for mod-
ninth through twelfth graders ate less than                                    erate physical activity, and 79 percent did not
five servings of fruits and vegetables per day                                 meet the guidelines for strenuous activity.
during the past seven days. Ninety two (92)                                    Forty two (42) percent of Alabama students
percent of Alabama students drank less than                                    did not participate in sufficient vigorous
three glasses of milk per day during the past                                  physical activity; 81 percent of students did
seven days, ranking the worst of all the states.                               not participate in sufficient moderate physical
                                                                               activity; 59 percent were not enrolled in
                            Adult Consumption of                               physical education class; 14 percent did not
                         Fruits and Vegetables per Day                         participate in any vigorous or moderate phys-
                                 Alabama 2003                                  ical activity; and 39 percent did not partici-
                    80                                                         pate in a sufficient amount of physical activi-
                    70
                                                    77.4                       ty.

                                                                               Attitudes
                    60
Percent of People

                                                                                  In October 2001, the Alabama
                    50                                                         Department of Public Health contracted with
                                                                               the University of Alabama in Birmingham
                    40                                                         (UAB) to conduct a baseline telephone survey
                                                                               of 400 adults on obesity issues in Alabama.
                    30
                                                                               Attitudes, beliefs, and health practices regard-
                    20
                                                                               ing weight were identified. The BMI's of
                                 22.6                                          respondents were calculated from self-report-
                    10                                                         ed heights and weights. Selected findings
                                                                               included:
                     0                                                            (1) Approximately ten percent of those
                              Consume 5       Consume less
                                or more           than 5                              who were calculated as overweight
                            servings per day servings per day                         responded they were not overweight.
                                                                                  (2) The most common reason for want-
Physical activity                                                                     ing to lose weight was to be able to
    There is little doubt that regular physical                                       see a child(ren) grow up.
activity is good for overall health. Physical                                     (3) The most frequent reasons for not eat-
activity decreases the risk for diseases such as                                      ing a healthy diet were: "it is too hard
colon cancer, diabetes, and high blood pres-                                          to count calories," "diets don't work,"
sure and is beneficial for bone health, enhanc-                                       “I am tired of hearing about dieting”,
ing mental clarity, and as a stress reducer. It                                       and "eating healthy is too expensive."

14                  Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
GENERAL                                                    of adult hypertension. Thirty-three percent of
CONSEQUENCES                                               the total Alabama adult population indicated
                                                           they had been diagnosed with hypertension.
Health concerns                                            In addition, 38 percent of the total adult
    The life expectancy rate for an Alabama                African American population is at risk for
citizen is 74.1 years as compared to 77.2 years            hypertension. The Alabama Department of
for the average adult in the United States. In             Public Health identified both high systolic
2001, the life expectancy for an Alabama                   and high diastolic blood pressures in Alabama
adult was comparable to the average                        adolescents.
American adult in 1981. This statistic places                  Cancer is the second leading cause of
Alabama 20 years behind the average state in               death accounting for 29,013 or 21.7 percent
terms of average life expectancy in the United             of all deaths from 1998 to 2000. The three-
States. Unless changes are made in lifestyles              year crude death rate for cancer for the total
and behaviors, today’s youth may be the first              population is 220.3 per 100,000 population.
generation in history to not outlive their par-            The African American and other races crude
ents.                                                      death rate is 184.4 and the Caucasian crude
    Some subgroups are at higher risk for obe-             death rate is 234.1 per 100,000 race-specific
sity and its associated health problems. Rates             population. The 1998 to 2000 age-adjusted
of chronic diseases in which obesity is a risk             death rate1 for cancer for the total population
factor are high in Alabama and dispropor-                  is 216.2 per 100,000 population. The
tionately high in similar subgroups. For
example, in 1998 age-adjusted cardiovascular                      Leading Causes of Death
mortality rates were substantially higher for                        in Alabama - 2002
African Americans (473.9 per 100,000) com-
pared to Caucasian (383.9 per 100,000). In
1998, the stroke mortality rate for African
Americans was 44 percent higher than for                              36.8
                                                                        All Other Causes 33%34.8
Caucasian.
    The top two causes of death in Alabama
are cardiovascular disease (CVD) and cancer.                                          28.4
Much research supports the nutrition and
                                                               Cardiovascular                Cancer 21%
physical activity impact on these diseases. In
                                                                Disease 36%
2002, CVD accounted for 36 percent of all
deaths. More Alabamians die each year from
CVD than from all forms of cancer com-
bined. Alabama ranks 6th in the nation in
heart disease deaths and 7th in stroke deaths.
                                                                                                Accidents 5%
Alabama ranks above the national average in                 Respiratory Diseases %5
deaths due to heart disease. African
Americans have the highest stroke death rate               African American and other races age-adjust-
in Alabama. Alabama ranked third in terms                  ed death rate is 243.1 and the Caucasian age

                            Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama   15
adjusted death rate is 208.9.                                   Economics
                                                                The report, "F as in Fat: How Obesity
Diabetes                                                        Policies are Failing in America," stated that
An estimated 17 million Americans (6.2 per-                     Alabama spent the equivalent of $293 per
cent of the population) now have diabetes.                      person on its 4 million plus residents last year
Alabama has one of the highest rate of diag-                    paying for health care costs related to obesity
nosed diabetes (8.4 percent). In 2003, the                      - the ninth highest amount in the nation.
age-adjusted prevalence of diagnosed diabetes                   Because of increases in health care costs and
ranged from a high of 10.9 percent in Puerto                    health insurance for state employees and pub-
Rico to a low of 4.9 percent in Colorado.                       lic education employees, the Legislature held
Diabetes is the sixth leading cause of death in                 a special session in November 2004 to address
Alabama with 3,964 or 3 percent of all deaths                   ways to contain the rise in health insurance
from 1998 to 2000. For African Americans                        costs.
and other races, diabetes is the fifth leading
cause of death. For Caucasians, diabetes is the
seventh leading cause of death.
True population statistics data and Alabama
data are not yet available regarding the preva-
lence of type 2 diabetes in school children.
However, verbal reports indicates that dia-
betes in children is growing. Because of ele-
vated risks in Alabama school students,
Alabama experiences an even greater potential
for type 2 diabetes in school-age children.

16   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
Healthy
       Alabama 2010

Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama   17
HEALTHY ALABAMA 2010

The overall goal for the Healthy Alabama                        usage, higher rates of obesity, and more people
2010 Objectives is to increase the life                         living a sedentary lifestyle and lower utilization
expectancy and quality of life for Alabamians.                  of preventive health care measures. These fac-
The disparity in life expectancy between                        tors result in higher death rates from chronic
Alabama and the remainder of the nation has                     conditions such as heart disease, stroke, and
actually grown wider in the past decade. A                      diabetes. The State Obesity Task force
number of factors that can adversely affect                     acknowledges these goals and will assist in
longevity include poverty, low levels of educa-                 efforts to reach them.
tional attainment, higher rates of tobacco

                                       Physical Activity and Fitness
 Adult Physical Activity
  1.1 Increase to 25 percent or more the proportion of adults aged 18 and older who engage regu-
      larly, preferably daily, in sustained physical activity for at least 30 minutes per day.
                                      AL Baseline         AL Target           US Baseline       US Target
 Adults 18 and older                   17 (1997)             25               23 (1995)            30

 Adolescent Physical Activity
  1.2 Increase to 60 percent or more the proportion of students in grades 9-12 who engage in
      moderate physical activity for at least 20 minutes a day for 3 days per week.
                                      AL Baseline         AL Target           US Baseline       US Target
 Students grades 9-12                  55 (1997)             60                  N/A              N/A

                                                     Nutrition
 Weight Status
  1.3 Reduce to 20 percent or less the prevalence of being overweight (defined as a body mass
      index at or above 27.8 for men and 27.3 for women) among adults aged 18 and older.
                                      AL Baseline         AL Target           US Baseline       US Target
 Adults 18 and older                   35 (1997)             20                  N/A              N/A

 Dietary Guidelines
  1.4 Increase to 40 percent or more the proportion of adults aged 18 years and older who meet
      the dietary recommendations of a minimum average daily goal of at least 5 servings of veg-
      etables and fruits.
                                      AL Baseline         AL Target           US Baseline       US Target
 Adults 18 and older                   17 (1997)             40                  N/A              N/A

18   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
Alabama State
          Obesity Task
              Force
Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama   19
ALABAMA STATE OBESITY TASK FORCE

HISTORY                                                         committee selected a chair. The task force,
    Despite limited resources, the Alabama                      with 92 total members, became six, separate,
Department of Public Health (ADPH) and                          yet coordinated committees all creating posi-
the University of Alabama in Birmingham                         tive working relationships. The committees
(UAB) pledged to work together to address                       developed realistic action steps from the
healthy opportunities for all Alabamians.                       established goals and objectives.
The obesity epidemic was acknowledged as
were different approaches that were being                       GENERAL GUIDING
taken across the state to address it. The first                 PRINCIPLES
Obesity Task Force meeting was held on May
4, 2004 in Montgomery. Over 70 representa-                      Multifaceted approach guidelines
tives attended from public health, academia,                        In developing a state obesity plan, a social-
health care, education, businesses, and com-                    ecological approach was used. This model
munity groups.                                                  was especially appropriate in addressing the
    The charge of the task force was to devel-                  very complicated weight issues as it includes
op and implement a comprehensive state plan                     influences at multiple levels: individual, inter-
to reduce obesity in Alabama among all seg-                     personal, organizational, community, and
ments of the population. The purpose was                        public policy. This ecological perspective
not to change the approaches already in                         includes the importance of approaching pub-
progress, but rather to help Alabama work                       lic health problems at multiple levels while
together as a whole. The task force members                     stressing interaction and integration of factors
agreed to utilize evidenced based practices in                  with and across the levels.
developing the plan. From the first meeting,                    Strategies compatible with this model include
it was clear the plan would be suitable for                     enhancing individual responsibility for posi-
Alabama, building on the state’s unique char-                   tive lifestyle change and garnering outside
acteristics and resources. Members agreed to                    forces through schools, worksites, and com-
address weight concerns through emphasizing                     munity settings.
a healthy relationship with food, a healthy                         At the center of the SEA is the individual
body weight, and a physically active lifestyle.                 surrounded by increasing larger circles of influ-
    During the first meeting, members self-                     ence. These areas, interpersonal, organization-
selected into committees: nutrition concerns,                   al, community, and policy will all influence
physical activity concerns, youth and families,                 personal choices. The relationship can be
community, data, and health care. The com-                      reciprocal; the environment affects health relat-
mittees met on a monthly basis from June                        ed behaviors and people through their actions
through November 2004 establishing goals,                       can affect the environment. The Alabama
adding additional partners, and reviewing                       State Obesity Plan is designed to enable per-
potential solutions. By January 2005, each                      sons to use the plan at any and all levels.

20   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
Individual                                                   portive of others and be good role models in
    Individuals are responsible for positive,                maintaining a healthy weight, eating a
sound, life style behavior choices that pro-                 healthy meal pattern, and being physically
mote a healthy body. To encourage this, a                    active.
positive message that promotes healthy eating                    The task force will work to increase adult
and increased physical activity through cul-                 knowledge and skills about being role models
turally relevant approaches will be used. The                for positive eating and physical activity
need to raise the awareness of the increased                 lifestyles in order to strengthen future genera-
obesity rates and decreased physical activity as             tion’s health outcomes. Additionally a focus
a serious health issue, its economic cost to                 on training adults who are parents, who work
Alabama, and its negative impact on the qual-                formally and informally with children and
ity of life exists.                                          teens, and adults who influence policy and
                                                             funding decisions will be needed.
Interpersonal/Group                                              Examples include an accountability system
    Alabama citizens are in multiple roles at                in families or with friends for eating healthy
any given time. A person may be a family                     food selections. Support can be offered
member, a friend, or a coworker/peer. All of                 through families and neighbors helping each
the roles provide a social identity and can                  other become more physically active by going
provide or offer support. In addressing obesi-               for a bike ride, inviting a neighbor to take a
ty issues, Alabama citizens need to be sup-                  walk, or playing outside with the children.

                     A Social-Ecological Model For Nutrition Evaluation
                                                                                          Social Structure, Policy
                                                                1                         Local, State federal
                           Spheres of Influence                                           policies and laws that
                                                                                          regulate or support
                                                                                          healthy actions
                            Social Structure, Policy, Systems
                                                                                         Community: Social
                                      Community                                          networks, norms
                                                                                         standards (e.g. public
                                                                                         agenda, media agenda),
                              Institutional/Organization                                 or other existing channels
                                                                                          Institutional/
                                                                                          Organizational: Rules,
                                      Interpersonal                                       regulation, policies and
                                   Lifestyle Influences                                   informal structures
                                                                                          (worksites, schools,
                                                                                          religious groups)
                                         Individual                                       Interpersonal
                                                                                          Interpersonal process
                                                                                          and primary groups
                                                                                          (family, peers, social
                                                                                          networks, associations)
                                                                                          that provide social
                                                                                          identity and role
                                                                                          definition
                                                                                          Individual: Individual
                                                                                          characteristics that
                                                                                          influence behavior such
    1 McElroy KR, Bibeau D, Steckler A. Glanz K. A perspective on health promotion        as Knowledge, attributes,
    programs. Health Education Quarterly 15:351-377. 1988.                                beliefs, and personality
                                                                                          traits

                              Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama      21
Institutional/Organizational                                    nities for physical activity by modifying com-
   Alabama’s businesses, industries, organiza-                  munity and school environments is needed.
tions, educational sites, including day care,                   Examples include churches, mosques, syna-
primary, secondary and higher education                         gogues and other faith organizations that
institutions, work places, medical settings,                    serve meals to members to provide healthy
and other places of employment will provide                     food selections and promote prayer walks or
opportunities to promote good health and                        exercise classes at the facility; and for civic
recommended behaviors. These increased                          groups to select a neighborhood environmen-
opportunities can be through formal chan-                       tal issue to address in efforts to promote
nels, such as rules and policies, or through                    walking.
informal channels, such as suggestions or
guidelines. Examples include employers                          Policy
encouraging physical activity breaks; healthy                       Alabama’s decision makers will be support-
food items being available in vending                           ive at local and state levels in creating oppor-
machines and in cafeteria selections; wellness                  tunities for healthy eating and physical activi-
programs providing information for all                          ty through policies and laws. This will
employees; and employers encourage or pro-                      require citizens to raise awareness and pro-
vide early assistance and appropriate preven-                   mote action among elected and appointed
tion/treatment interventions.                                   officials, foundations, and potential private
                                                                sector partners regarding the need for policy
Community                                                       change, environmental change, and adequate
    Alabama’s communities, social networks,                     resources to address overweight/ obesity in
and faith communities that exist formally or                    Alabama.
informally among individuals, groups, and
organizations will promote and support                          Evidenced-based approaches that work
lifestyle choices to promote healthy bodies.                        The obesity epidemic is a serious health
To improve our communities and to make                          problem that calls for immediate action to
them places where people are healthy, safe,                     reduce its prevalence. Therefore, the task-
and cared for, will take a unified effort.                      force felt that actions should be based on evi-
Collaborating effectively with other individu-                  dence-based research. These interventions or
als and organizations, both inside and outside                  treatment approaches have been scientifically
the community, is necessary. This requires a                    demonstrated to be effective, regardless of the
process of people working together to address                   discipline that developed them. This plan is
key issues that are important to them. The                      based on research findings that validate the
community environment will establish and                        promoted concepts. However, the plan will
promote healthy eating and active lifestyles as                 not be limited only to printed evidenced-
the norm rather than the exception.                             based documentation.
Community based strategies to support
healthy eating and physical activity need to
be tailored for the individual community.
Access to healthy foods choices and opportu-

22   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
Alabama’s State
    Plan Addressing
        Obesity
Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 23
ALABAMA’S STATE PLAN ADDRESSING OBESITY

GENERAL COMMENTS                                                made, specifically that schools should provide
                                                                healthy food choices and address physical
    This report presents a plan with goals, rec-                education options. Nutrition changes include
ommendations, strategies, and activities                        foods served through the cafeteria, in vending
encouraging interventions that promote                          machines, and school stores; that fund raising
healthy eating and physical activity as                         policies should utilize healthy foods or non-
approaches for Alabamians to reach and                          food items; and that teachers should use non-
maintain a healthy weight. In developing the                    food items as rewards for classroom perform-
plan, it was recognized that a great potential                  ance in place of candy. School environment
for synergy with enhanced communication                         approaches include the recommendation to
and coordination among various groups with-                     complete an assessment, such as The School
in the state exists. For example, media mes-                    Health Index, to identify potential areas for
sages can be tailored to be put into practice at                needed change. Physical activity recommen-
schools, work places, and community sites.                      dations include evaluating all physical educa-
There will also be benefits of learning from                    tion (PE) waivers; having PE taught by certi-
successes across the state. The successful                      fied PE teachers in all grades; promoting life-
approaches can be tailored and implemented                      time, enjoyable activities; reviewing the quali-
in a different location. This coordinated                       ty of the classes taught; and limiting the stu-
focus will assist in using limited resources and                dents in each class to a specified ratio of stu-
generating new resources by involving the                       dents to teachers.
whole state.
    Committee members agreed that obesity is                    HOW TO USE THE STATE
a very complex issue. Therefore, approaches                     OBESITY PLAN
taken will consider the relationships with
food. These relationships will be explored to                       The outlined approaches will not be suc-
address cultural, emotional, and traditional                    cessful without support of representatives
beliefs that determine eating habits.                           from diverse segments of society, industries
    The plan does not focus on changes need-                    and businesses, institutions, agencies, media,
ed in the school environment. This is                           health care, families, schools, communities,
because the State Department of Education                       non profit organizations, places of faith, and
developed a Student Health Task Force. The                      so on. Implementing the plan must be a
education task force met from September                         statewide effort. Special attention may be
2004 through May 2005 in developing nutri-                      needed in communities that experience health
tion and physical activity related recommen-                    disparities and have environments that are
dations for public schools. The State Obesity                   not supportive of healthy nutrition habits or
Task Force supports the recommendations                         physical activity opportunities. The plan can

24   Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama
be used by individuals at both the statewide               health consequences in individuals who are
and local levels. Agencies, institutions, and              overweight or obese. The first group may or
groups can implement the strategies in work                may not acknowledge they have a weight
plans. Key stakeholders and decosionmakers                 problem. In fact, based on a survey complet-
can use the report to increase awareness. It is            ed in 2001, almost 10 percent of Alabamians
the Task Force’s hope that the plan can stimu-             who were overweight did not realize they
late new ideas, partnerships, and coalitions.              were. This group lacks an understanding in
                                                           the severity of the health risks associated with
                                                           obesity and does not display a working
SIX WORKING GROUPS:                                        knowledge of how to transform eating pat-
                                                           terns into healthier food intakes.
PERSPECTIVES IN                                            Interventions will include educational oppor-
ALABAMA                                                    tunities to include interactive sessions for
                                                           learning implementation skills. Topics will
NUTRITION                                                  include, but not be limited to:
SUBCOMMITTEE                                               • Health problems associated with obesity
                                                           • Portion sizes
Summary:                                                   • Healthy food choices
    The goal is to promote both primary and                • How to read food labels
secondary prevention of obesity.                           • How to prepare foods
    The committee’s consensus is there are
two groups who would greatly benefit from a                    The second group knows the importance
nutrition intervention plan. The first group               of an appropriate body weight and increased
does not understand the health importance of               physical activity level, but is not convinced to
weight control and does not display an                     make lifestyle changes. Educational efforts
understanding of how to transform eating                   for this group will need to address:
patterns to consume healthier foods. The                   • Changing knowledge into behavior
second group has “head knowledge”, but due                 • Making appropriate food choices that are
to environmental conveniences, personal                        easy and convenient
beliefs, and values is not convinced to make               • Learning healthier ways to prepare favorite
lifestyle changes.                                             foods
    Both groups will benefit from a compre-
hensive media plan and other approaches to                     Both groups will benefit from environ-
promote healthy lifestyles. Such interven-                 mental improvements to foster healthier food
tions could include community level educa-                 as the easier, low-cost choice. The environ-
tion efforts, healthier eating choices to be               mental changes will be supplemented with
readily available, and opportunities for reward            educational messages that address overcoming
incentives through work or insurance plans.                barriers to losing weight.
                                                               Educational strategies will include:
Specific details:                                          • Providing programs to explore aspects of
   The nutrition subcommittee agreed that                      emotional eating; the uses, values, and
there are different levels of understanding of

                             Strategic Plan for the Prevention and Control of Overweight and Obesity in Alabama 25
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