1. Obesity Prevention Among Indigenous Peoples and Ethnic Minorities Mihi Ratima Brigham and Women’s Hospital

2. Rationale Ethnic inequalities Burden of disease Preventable International relevance

3. Table 1: Prevalence (%) of overweight and obesity (BMI≥25) among US women by ethnicity Age (years) Non-Hispanic White Non-Hispanic Black Mexican American ≥2057.277.271.7 20-3949.070.361.8 40-5959.981.580.9 ≥6066.782.273.9 Source: Hedley AA et al, JAMA 2004;291:2847-50, Data from 1999-2002 US NHANES

4. Research objectives Identify distinctive factors that influence overweight and obesity prevalence among indigenous peoples and ethnic minorities, and implications for intervention Identify innovative approaches, strategies and delivery systems for obesity prevention among these groups, particularly in primary care systems

5. Project design Literature review Key informant interviews Case studies

6. Key informants n=10 Population group specific expertise Health care stakeholders Stages of life cycle Intervention levels Geographical spread

7. Case studies ‘Southcentral Foundation’, AK Indigenous driven, integrated approach ‘Healthy Eating Active Communities’, CA Primary health care/public health partnership, evaluation framework ‘Fitness in the City’, MA Locally tailored, wide range of expertise

8. Distinctive factors and implications for intervention Culture Lifestyle Environment Primary health care Genetics/biological

9. Culture “There has been so much shame associated with being Native that has led to lots of problems including around food. Promoting cultural pride, the promotion of self esteem…I think would be very important”

10. Lifestyle. “You need to know the…day to day reality of what happens …and put it in the context of all the other issues that people are dealing with”

11. Environment “It’s more the exposures that are driving it [the obesity epidemic] and less ability to work around them combined with some attitudes that might make people more vulnerable to these exposures”

12. Primary health care Access Fragmented Priority Targeting and piloting Identification of risk Chronic care model Intersection of health care/public health

13. Characteristics of interventions Community based participatory activities – ‘Pathways’ Culture as a vehicle – ‘Hip Hop to Health’ Multilevel – ‘VERB’ Primary health care/public health partnerships – ‘Boston YMCA’

14. Preliminary findings Align interventions to realities Surface level tailoring versus deep structure tailoring Policy and environmental context for individual focused interventions Practical measures in primary health care Primary health care/public health partnership Multilevel model Evidence – evaluation, measurement, piloting

15. US policy implications Universal incentives across insurers Primary health care/public health partnerships Health policy versus public policy ‘One size fits all’ approach Equity focused health impact assessment Political will – build on progress, focus on children

16. New Zealand policy implications Reinforces current framework (priority to primary health care/public health/prevention, addressing ethnic inequalities, deep structure tailoring) Coalition building Strengthening public policy Equity focused health impact assessment Policy and environmental context for individual level interventions Specific best practice directions Evidence –local policy packages, indicators