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Physical Activity Promotion: Prevention of
Chronic Disease Morbidity & Mortality
Antronette (Toni) Yancey, MD, MPH, FACPMAssociate Professor, Dept. of Health
Services,Co-Director, Ctr. to Eliminate Health
DisparitiesUCLA School of Public Health
www.ph.ucla.edu/cehdwww.toniyancey.com
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Unhealthy eating and inactivity are leading causes of death in the U.S.
HHS estimates that unhealthy eating and inactivity contribute to 310,000 to 580,000 deaths each year. That’s 5 times more than are killed by guns, HIV, and drug use combined.1
The typical American diet is too high in saturated fat, cholesterol, salt, and refined sugar and too low in fruits, vegetables, whole grains, calcium, and fiber.
Such a diet contributes to four of the seven leading causes of death and increases the risk of numerous diseases, including:
heart disease diabetes cancer high blood pressure obesity osteoporosis stroke
60% of Americans are at risk for health problems related to lack of physical activity (ie: get less than 30 minutes of moderate activity 5 or more times per week). 2
1. Heart Disease 724,900
2. Cancer 541,400
3. Stroke 158,400
4. Chronic Obstructive Pulmonary Disease 112,700
5. Accidents 97,800
6. Pneumonia and Influenza 91,900
7. Diabetes 64,900
8. Suicide 30,500
9. Nephritis 26,200
10. Chronic Liver Disease/Cirrhosis 25,100
11. Septicemia 23,800
12. Alzheimer’s 22,700
13. Homicide and Capital Punishment 18,400
14. Atherosclerosis 15,400
15. High Blood Pressure 14,300
Diet and Physical Inactivity 310,000-580,000
Tobacco 260,000-470,000
Alcohol 70,000-110,000
Microbial Agents 90,000
Toxic Agents 60,000-110,000
Firearms 35,000
Sexual Behavior 30,000
Motor Vehicles 25,000
Drug Use 20,000
Leading Contributors to Premature Death1
Leading Causes of Death3
(Diet is a leading risk factor for causes of death shown in bold or green.)
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The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin
All patients had impaired fasting blood sugars, but were not diabetic
Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week
They were followed over 2.8 years
DIABETES PREVENTION PROGRAMDIABETES PREVENTION PROGRAM
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DPP Research Group. N Engl J Med. 2002;346:393-403.
Lifestyle intervention was much more effective than either placebo or metformin
DIABETES PREVENTION PROGRAMDIABETES PREVENTION PROGRAM
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Fitness & Mortality
•Low fitness is bad for health
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Walking & CVD •Walking as little as 5 mins. daily is beneficial for fitness
•30 mins. daily provides best health benefit (heart disease prevention)
•60 mins daily can cause reversal of heart disease
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Physical Activity& Risk of Common
Cancers Colon: 30-40% decreased risk among active
men & women (Rectal—no association) Breast: substantial evidence for dec risk;
strength of assn--time period may be critical Prostate: findings inconclusive Possible mechanisms: 1. decreased GI transit time (dec carc expos) 2. enhanced immune function (moderate PA) 3. lowered levels of reproductive hormones
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Population Attributable Fraction Cancer Mortality – Male Never Smokers
PopulationBMI Exposure* RR† PAR (%)
25.0-29.9 42% 1.1 4.0%
30.0-34.9 21% 1.4 6.8%
>35.0 13% 1.3 3.4%
14.2%
*NHANES 2000, men age 50-69
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Population Attributable Fraction Cancer Mortality – Women Never Smokers
PopulationBMI Exposure* RR† PAR (%)
*NHANES 2000, women age 50-69
25.0-29.9 29% 1.1 3.3%
30.0-34.9 23% 1.3 6.1%
35.0-39.9 11% 1.4 3.5%
>40.0 8% 1.9 7.0%
19.8%
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YEAR % Obese % No LTPA
1991 10% 23.3%
1995 14.4% 22.7%
1998 16.8% 25.5%
1999 19.6% no data
2000 19.2% 26.5%
20
15
10
5
30
25
20
15
1991 1995 1998 2000
BRFSS DATA
http://apps.nccd.cdc.gov/brfss/Trends/trendchart_c.asp?state_c=CA&state=US&qkey=10020&SUBMIT1=Go
% obese
%No
LTPA
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Lesser Effectiveness of Key Environmental Interventions
in Underserved Groups: Example
Posting of Signs Promoting Stair Usage(suburban Baltimore mall)
Overall, stair use increased from 4.8% to 6.9%, 7.2%, depending upon which of 2 signs used
Among whites, increased from 5.1% to 7.5%, 7.8%
Among blacks, changed from 4.1% to 3.4%, 5.0% Among n’l wt, inc from 5.4% to 7.2%, 6.9% Among overwt, inc from 3.8% to 6.3%, 7.8%
Andersen, Franckowiak, Snyder et al., Ann Int Med, 1998;129:363-369.
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Excess physical environmental risk in
underserved communities: Pervasive targeted commercial marketing Distance to private fitness facilities Few worksite fitness opportunities Few/poor neighborhood recreation facilities Lesser neighborhood safety Poorer public/less reliable private transportation Poorly equipped facilities Poorly maintained sidewalks, e.g., cracks, litter, overgr.
foliage Fewer traffic calming devices, e.g., speed bumps Ample car “accommodation,” e.g., parking, high-
speed/multi-lane roads=“Move insecurity”1, 2
1Jahns & Jones, AJPM 2004;26:186 2Yancey, AJPM 2003;25(3Si)Adapted from Kumanyika S. Obesity in Minority Populations. In Fairburn G & Brownell K, Eating Disorders and Obesity. A Comprehensive
Handbook, 2002.
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Marketing Expenditures, CMR, 2005(in millions)
$123.4
$22.8
$0.0
$35.7
$17.5$10.5
$43.9
Coca Cola Diet Coke Odwalla Minute Maid Dasani Powerade Sprite
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Which billboard(s) is (are) about physical activity?
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Media Project: five-city outdoor advertising content analysis
Funded by CA DHS, UT, Penn & RWJFCities: LA, Philadelphia, Austin, Sacramento,
FresnoComparing high & low SES predominantly
black, Latino, & white neighborhoods (all 6 categories not available in all cities, e.g., high SES black in Sacramento and Fresno)
Utilizing secondary data from CHIS, LACHS, grocery store scanner (MOU with major supermarket chain) purchase data for correlational analyses
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Preliminary findings
Absence of billboards and near-absence of other outdoor advertising in affluent white neighborhoods—existing ads unrel. to weight
Essentially no outdoor advertising of PA-promoting goods & services in any community, but large amount sedentary entertainment & transportation ads in low-inc. communities
Pervasiveness of advertising in low-inc. white & Latino communities, but more fast food, sugar-sweetened and alcoholic beverages in latter
City of LA has moratorium on new billboards, but in low-inc. Latino comm., large # of new side of building ads similarly framed
Findings must be interpreted in light of historical covenants, fewer ads trad. In unincorp. areas
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Excess sociocultural environmental risk in
underserved communities: Cultural attitudes about work, activity, rest Fears about safety Prevalent obesity/norms Female roles Cultural reverence for cars Hairstyle-related concerns about sweating Increased screen time, e.g., TV viewing, movie-
going
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LA’s ESPN Radio 710 AM Ad
“We’re the prime rib on a dial full of tofu”
--March 2006
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Cultural reverence for SUVs?
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Hunter-gatherersHunter-gatherers 5000 cal 5000 cal
Agriculture Agriculture 6000 cal 6000 cal
Laborers Laborers 3000 cal 3000 cal
Office WorkersOffice Workers 1800 cal 1800 cal
1 million 1 million yrs agoyrs ago
10,000 10,000 yrs agoyrs ago
19151915
NOWNOW
AVERAGE ENERGY AVERAGE ENERGY EXPENDITUREEXPENDITURE ESTIMATESESTIMATES
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Physical Activity Levels, %L.A. County Adults, 1999
District Sedentary (<10 min/wk)
County 41 +1Compton 45 +6
South 50 +9
Inglewood 46 +6
Long Beach 37 +5
West 31 +3
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Physical Inactivity Levels: TV viewing/computer use, %
L.A. County Adults, 1999Ethnic Group TV/Computer Use
>3 hrs/d (95% CI)
County total 21.7 20.6-22.9African Americans 36.5% 32.4-40.5
American Indian
34.2% 16.1-52.3
Asian/Pacific Isl.
21.1% 17.6-24.6
Latino 15.8% 14.3-17.3
White 24.3% 22.4-26.2
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Self-Perceived Overweight by Ethnicity & Gender,
% LA County Adults
Female Male
AA Overwt 67 29
AA Nml wt 20 --
API Overwt 86 46
API Nml wt 28 10
Lat Overwt 80 41
Lat Nml wt 26 9
W Overwt 84 46
W Nml wt 21 4
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Influence of Self-Perceived Weight Status on PA,
% LA County Adults Overall, regardless of BMI, those perceiving themselves
as overweight more sedentary than those with average wt. self-perception (45% vs. 30%)
Influence most pronounced for males and normal weight individuals
Overwt. self-perception not assoc. with sedentariness among white women, the only one of the 6 ethnic-gender groups included in which BMI<25 normative
In multivariate analysis, self-perceived overweight, not BMI, predicts sedentary behavior (OR=1.40, CI 1.19, 1.64)Yancey, Simon et al., Obes (Res) 2006;14:980-8. Yancey, Wold et al., Am J Prev Med, 2004;27:146-52.
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Current Population Status
Little change in leisure time physical activity (PA) during past several decades of obesity increases (1 in 5), but marked increases in sedentary entertainment, transportation, and other ADLs (Sturm, 2004)
PA levels within increasingly sedentary, deconditioned, overweight population are unlikely to increase primarily through individual motivation and volition—relatively little demand for goods & services or political will to push for aggressive legislative policy change, e.g., radical alteration in the built environment favoring bicycle, pedestrian, and mass transit over private automobile transportation
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Daily “Dose” (Rx) of Physical Activity
30-60 minutes/day on most (at least 5) days of the week
At least moderate intensity (=walking 1 ½ to 2 miles in 30 minutes)
Can be broken up into 10-minute stretches throughout the day
Every calorie burned is one that doesn’t end up around your waist!
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The goal was to study the reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin
All patients had impaired fasting blood sugars, but were not diabetic
Their were randomized to placebo, metformin or a lifestyle modification with goal of at least 7 % weight loss, at least 150 minutes of exercise per week
They were followed over 2.8 years
AFRICAN AMERICAN WOMEN & HEART DISEASEAFRICAN AMERICAN WOMEN & HEART DISEASE
DIABETES PREVENTION PROGRAMDIABETES PREVENTION PROGRAM
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How much is enough?
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Population benefit estimates of risk factor
change: PA 3-minute bouts of PA 10 times per day lowers
serum triglycerides to same extent as 1 continuous 30-minute bout of PA (Miyashita et al., 2006)
Maintenance of moderate PA is assoc. with a 1/3 to 2/3 lowering of Type 2 diabetes (DM) incidence over 4-14 yrs (Clark, 1997)
Type 2 DM risk was 50% lower among individuals physically active at any level, and 66% lower among those at least moderately active (James et al., 1998)
Sedentary behaviors (e.g., TV watching) as well as sub-optimal >moderate PA levels contributed to DM & obesity risk over 6 yrs in women (Hu et al., 2003)
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Population Obesity Control:
Early stage in developmentStrategically, why focus on PA promotion first? Less controversy, conflict, stigma than surrounding
diet/nutrition “Deep pocket” business interests, e.g., Nike & 24-
Hour Fitness, stand to benefit from success of efforts (vs. “Big Food” losing $ because can’t as readily induce over-consumption of H2O, whole grains, legumes, F+V)
Cheaper & easier—10 min. supply 1/3 of PA “RDA” May positively influence food preferences
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Population Obesity Control:
Early stage in developmentTo avoid exacerbating health risk/disease
burden disparities, push strategies (skip-stop/slowed hydraulic elevators, restricted proximal parking, non-discretionary time exercise breaks, walking meetings) should be prioritized over pull strategies (building trails & parks, offering gym membership subsidies/discounts) at this early stage of development of environmental and policy approaches—make it easier to do it than not to do it!
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Population Obesity Control:
Early stage in development (cont.) Synergy will occur when supply (physical
environmental access & appeal) meets demand (individual/ sociocultural motivation, prioritization, valuation, skills/interests, political will)
Demand must be created—need to structure in “unavoidable” experiences which increase aerobic conditioning, build skills & self-efficacy, foster enjoyment, elevate mood & energy, increase taste for water-bearing foods & less highly-sweetened beverages
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Spectrum of Prevention:Health behavior change
model Level 1: Strengthening individual knowledge
and skills Level 2: Promoting community education Level 3: Educating service providers Level 4: Fostering coalitions and networks Level 5: Changing organizational practice Level 6: Influencing policy and legislation
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Spectrum of Prevention:
Shift in health promotion fieldThe most effective and sustainable PH
intervention approaches of the past two decades are the more “upstream” ones (structural/environmental vs. individual-level), involving social norm change:
Tobacco control Alcohol consumption and driving Breastfeeding Littering and recycling
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Spectrum of Prevention(2nd level)
Level of Prevention
Definition of Level
Examples of Obesity Prev.Efforts
Promoting community education
Reaching groups of people with information and resources to promote health
Community walkathons / fitness eventsMedia campaignsNeighborhood canvassing for healthy food optionsCommunity gardens
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ROCK! Richmond
Community-level fitness promotion initiative of Richmond City DPH/Medical College of Virginia
3 major components: (1) free fitness instruction in CBOs in underserved areas; (2) environmental changes in conduct of city business (e.g., low-fat/ high-fiber food choices at city functions); (3) social marketing effort to reinforce norms supporting PA & healthy eating
Successful in recruiting disproportionately among population segments at highest risk for chronic disease (older, black, female, family hx of CA, CVD)
Yancey, Jordan, Bradford et al., Health Prom Practice, 2003
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Spectrum of Prevention(5th level)
Level of Prevention
Definition of Level
Examples of Obesity Prev.Efforts
Changing organizational practice & policy
Adopting regulations and shaping norms to improve health
Protocols for MD assessment, sliding fees, counseling & referralWorksite policies (movement breaks, vending, refreshments)School PE content & delivery
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Translating Evidence-Based CDC/ACSM Recommendations
into Culturally-Targeted Intervention Integrating 10-’ PA bouts into organizational routine:
Minimal intensity environmental intervention, e.g., stair prompts
Short bouts accommodate higher proportion sedentary individuals (incremental change)
Variable (max moderate) intensity, low-impact PA accommodates higher proportion overweight/obese and disabled individuals (higher perceived exertion, discomfort, functional limitations)
Passive (“push”) strategy relies less on individual motivation & facility access (early adopters scarce)
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Translating Evidence-Based CDC/ACSM Recommendation
into Culturally-Targeted Intervention Integrating 10-’ PA into organizational routine:
Movement to music integral to African-American, Latino culture—dancing normative for adults
Short bouts minimize perspiration, hairstyle disturbance
Social support & conformity desires drive participation (collectivist vs. indiv. orientation)
Addresses less activity conducive outdoor environments (safety, utility, aesthetics)
Designed for organizational settings for work, worship, other purposes--less disposable t, $
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Lift Offs Work!: the Rapidly Growing Evidence
Base Documented individual and organizational
receptivity to integrating PA on paid work time Contribute meaningfully to daily accumulation of
MVPA Motivational “teachable moment” linking
sedentariness to health status for inactive folks Improvements in clinical outcomes from as little as
one 10-min. break/day—BP, BMI, waist circ., mood, attention span, cumulative trauma disorders
“Spill-over” or generalization to inc. active leisure Favorable cost-benefit ratio, eg, L.L. Bean mfg
plant
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LAC Fitness & Wellness Study:design
Randomized, controlled, post-test only, intervention trial testing the effects of incorporation of a 10-min exercise break into staff meetings & training seminars lasting > 1 hr
Outcome measures: (1) participation by sedentary/overweight individuals; (2) mood/affect; (3) satisfaction with health status/fitness level
26 meetings (11 intervention, 15 control) with 449 county employees, mostly women of color
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LAC Fitness & Wellness Study:
Results (cont.) More than 90% of meeting attendees participated in the exercises
Among relatively sedentary participants: Intervention participants’ satisfaction with fitness
levels more highly correlated with PA stage of change (r=0.59) than controls (r=0.38, z=-2.32, p=0.02)
Among sedentary participants: Intervention participants’ self-perceived health
status ratings were significantly lower than controls (OR=0.17; 95% CI=0.05, 0.60; p=.0003
Yancey, McCarthy, Taylor et al. 2004;38:848-856
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Fuel Up/Lift Off! LA
Video/audio (DVD/CD) excerpt: movement break (Lift Off)
demonstrationwww.ph.ucla.edu/cehd
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Propuesta de colaboraciónImplementación de la pausa para la Salud:
Evaluar los factores de riesgo cardiovascular previo
a la intervención de actividad física.
Promover de 15 a 20 minutos de actividad física dentro de la jornada laboral, iniciando con 10 minutos hasta alcanzar máximo 20 minutos.
Promover la orientación alimentaria dentro de la jornada laboral.
Logros alcanzados en un año 0.4 kg/m2 menos de BMI (1 kg) y 1.6 cm menos de cintura promedio en los trabajadores en un año.
Lara A, Yancey A, Tapia-Conyer R et al., in preparation, 2006
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Community Health Council’s (CHC’s) REACH 2010 demonstration project--
African Americans Building a Legacy of Health
Intervention: Multi-component, centered around modeling the behaviors promoted (“walking the talk”)–(1) incorporation of fitness breaks into meetings, events and other gatherings; (2) provision of wellness training focused on changing the norms of organizations to incorporate PA & healthy food choices into their regular conduct of business (organizational wellness); (3) provision of a personal training experience to key organizational leaders; (4) development of a small grants program for ID/creation/promotion of PA opportunities.Sloane, Diamant, Lewis et al., J Gen Int Med 2003;18:1-8
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CHC’s African Americans Building a Legacy of Health:
Process evaluation
Measures: Primary dependent measure–level of organizational support for physical activity integration, as reflected in intensity of interventions selected for participation; Results: Nearly half (>100) of the 220 participating organizations demonstrated active support for physical activity integration, with >25% committed at the highest level of support.
Yancey, Lewis, Sloane et al., J Pub Health Mgmt Prac, 2004;10(2):118-123
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CHC’s African Americans Building a Legacy of Health:
Organizational wellness outcome evaluation
Participants: 35 organizations, >700 staff/ members/clients, 1o overwt./obese black women
Measures: Primary dependent—BMI; Secondary—affect, F+V intake, PA level
Results (post-intervention f/u):12-week intervention—dec. feelings of
sadness/depr. (p=0.00), inc. F+V (+0.5 svgs, p=0.00), marginally dec. BMI (-0.5 kg/m2 , p=0.08)
6-week intervention (re-tooled)—inc. #days in which participated in vigorous PA (+0.3 days, p=0.00)
Yancey, Lewis, Guinyard et al., Health Prom Prac, 2006;7(3):233S-246S
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California Fit WIC Staff Wellness Training
AIMS: To provide skills and tools to influence
workplace organizational practices and cultural norms to promote physical activity & healthy eating among staff
To provide skills and tools to influence staff to promote physical activity & healthy eating among WIC clients/families
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California Fit WIC Staff Wellness Training
Training sessions included: Engagement around ubiquitous nature of the
problem (“toxic” environment surrounding us) Skills training in workplace practice change
(e.g., movement breaks, walking meetings, leading co-workers to stairs vs. elev., healthy refreshments & identifying practical strategies to integrate PA (parking farther away, walking around children’s play area, carrying a basket vs. pushing a grocery cart)
Empowerment thru provision of tools, e.g., videos, audiotapes, bands, pedometers
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WIC Staff Wellness TrainingWIC Staff Wellness Training
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California Fit WIC Staff Wellness Training
Significant findings: Increased perceived workplace support for staff
PA (96 vs 58%, p=.002) and healthy food choices (85 vs 28%, p=.001)
Change in types of foods served during meetings (72 vs 24%, p=.002) & PA priority in workplace (96 vs 71%, p<.02)
Increased self-reported counseling behaviors with WIC parents promoting physical activity (64 vs 35%, p<.05) & sensitivity in handling weight-related issues (92 vs 58%, p<.01)
Crawford, Gosliner, Strode et al., Am J Public Health, 2004
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Community “Cost-Sharing”
1. Leverage funder and/or regulatory roles (foundation, especially government) to mandate healthy/fit workplace practices, with added resource allocation (e.g., 5%)
2. Change internal organizational culture (social norms) to create healthy/fit health & social services agency workplaces (“Walking the Talk”)
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Community “Cost-Sharing”
“Healthy/fit” organizational PA promotion practices include core & elective components, e.g., 10’ movement (or walking) breaks in meetings/ functions & at certain time(s) of day; walking meetings; stair prompts; leading employee groups to stairs in moving between work activities; restricted near parking; incentives for distant parking; model & reward fidgeting and lifestyle PA integration (e.g., less high heel & tie wearing, more pedometer wearing, formal recognition/kudos to those who jog or swim during lunchtime)
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Community “Cost-Sharing”
3. Encourage local school officials to:a. Train teachers of PE in SPARK-type models emphasizing coop. vs. compet., engaging all kidsb. Move student drop-off location as far away from door as possible, e.g., behind playing field, to maximize distance youth must walk to attend classc. Incorporate Take 10!, Lift Off! or other exercise breaks into academic curriculum 2x/day, eg, mathd. Incorporate structured exercise breaks into PTA meetings, school board meetings, community dialogues, staff meetings & other gatherings to raise visibilty/priority of PA promotion in addressing childhood obesity
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“We must become the
change we wish to see in the world.”--Mahatma Gandhi
Community “Cost-Sharing”