1. Evaluating State Public Health Nutrition Programs Marilyn Sitaker, MPH, Epidemiologist Cardiovascular Disease, Diabetes, Nutrition and Physical Activity Section, Washington State Department of Health

2. Learning Objectives for this Lecture Identify sources of data for nutrition and physical activity surveillance used for state-level planning and monitoring. Describe the strengths and weaknesses of existing data and data systems for state level practice Analyze the application and politics of the use of data at the state level for reports, policy development, and performance measures. Apply these understandings to state level evaluation of the Washington State Plan for Nutrition and Physical Activity

3. Washington State Plan for Physical Activity and Nutrition Purpose: 1. Slow the increase in the proportion of adults who are obese 2. Reduce rates of chronic disease 3. Improve the quality of life Overarching goals: · * Increase the proportion of adults and children who have diets that reflect the Dietary Guidelines for Americans. · * Increase the proportion of adults and children who meet the physical activity recommendations.

4. Objectives of the State Plan Nutrition Objectives: 1. Increase access to health promoting foods 2. Reduce hunger and food insecurity 3. Increase the proportion of mothers who breastfeed their infants and toddlers Physical activity Objectives: 1. Increase the number of people who have access to free or low cost recreational opportunities for physical activity 2. Increase the number of physical activity opportunities available to children 3. Increase the number of active community environments

5. Nutrition Sub-objectives: Increase access to health promoting foods Increase the consumption of vegetables and fruits. Assure that worksites provide healthful foods and beverages Ensure that K-12 schools provide healthful foods and beverages Reduce hunger and food insecurity Provide adequate support for nutrition and food programs Improve access to nutrition programs Increase the proportion of mothers who breastfeed their infants and toddlers Assure that health care settings, child care facilities, and worksite environments are breastfeeding-friendly.

6. Physical Activity Sub-objectives: Increase the # of people who have access to free or low cost recreational opportunities for physical activity Adequate funding for state and local recreational sites and facilities. Model policies to increase access to public facilities for PA Increase the number of worksites with policies that facilitate opportunities for PA Increase the # of physical activity opportunities available to children School based curricula and policies for quality, daily physical education Policies to provide K-12 students with opportunities for PA outside of P.E. Class Replace sedentary behaviors, such as watching television, with physical activity Increase the # of active community environments in Washington State Use urban planning approaches – zoning and land use. Change transportation policy to promote non-motorized transportation Enhance safety and perceived safety to improve walkability and bikeability

7. Structures, Policies, Systems Local, state, federal policies and laws to regulate/support healthy actions Institutions Rules, regulations, policies & informal structures Community Social Networks, Norms, Standards Interpersonal Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs Levels of Influence in the Social-Ecological Model Focus of the Washington State Plan for Nutrition and Physical Activity

8. Environment What do we mean by “Environment?” Physical Safe walking paths, home gardens, fresh produce in local markets Sociocultural Value that schools place of physical education; teachers serve as role models Policies Active transport given priority. Zoning for walking or cycling; protecting open spaces Economic Monetary incentives/ disincentives in form of taxes, pricing policies & subsidies

10. Evaluation of the State Plan Statewide Assessment Level 1: Monitor progress on implementation of State Plan & meeting plan objectives Level 2. Monitor environmental and policy efforts related to nutrition and physical activity Level 3: Ongoing monitoring of long term objectives: nutrition & physical activity; obesity; and prevalence of chronic diseases

11. Evaluation of the State Plan Statewide Assessment Level 1: Monitor progress on implementation of State Plan & meeting plan objectives 1.Increase access to health promoting foods 2.Reduce hunger and food insecurity 3.Increase the percent of mothers who breastfeed their infants and toddlers 4.Increase the number of persons in communities who have access to free and low cost recreational opportunities for physical activity 5.Increase the number of physical activity opportunities specifically available to children 6.Increase the number of active community environments

12. Evaluation of the State Plan Statewide Assessment Level 2. Monitor environmental and policy efforts related to nutrition and physical activity School Health Policy Survey: School Health Profiles, a CDC- sponsored survey Worksite Policy Survey: DOH-sponsored survey Community Poll: DOH-sponsored survey Healthcare Quality: DOH-sponsored survey

13. Worksite Policy Survey Sector: Worksite Access to Healthy FoodsBreastfeedingFree or Reduced cost opportunities for physical activity Increase Active Community Environments Data Collection Tool: Worksite Survey  Has a written policy for healthy foods at meetings.  Has a place for employees to sit & eat meals  Has microwaves employees can use to cook their food  Has refrigerators for employees to store their food  Low-fat milk, fresh fruits & vegetables, water, 100% juice, and low fat snacks are available in cafeteria.  Low-fat milk, fresh fruits & vegetables, water, 100% juice, and low fat snacks are available in vending.  “Healthy food” labeling used in cafeteria  “Healthy food” labeling used in vending  Has a written breastfeeding policy.  Allows flexible schedule with time To pump or breastfeed.  Has a designated breastfeedin g room or area.  Breastfeeding room has electrical outlet, locking door, sink with soap & water, refrigerator to store milk.  Has a policy for employees to use paid time or flex time for exercise  Provides subsidy to fitness clubs or gyms  Has a policy to encourage employees to take stairs (in buildings with elevators present)  Has signs to promote stair use (in buildings with elevators present)  Has policies to encourage alternative transportation to work  Has policies to encourage alternative transportation to work (walk/bike/public transportation)

15. Community Environments Poll Sector: Community Access to healthy foodsFree or reduced-cost opportunities for physical activity Data Collection Tool: Community Poll  Healthier food choices are clearly labeled in the store, such that nutritional information, such as the fat and calorie content, can be evaluated.  Whole grain foods available in store. 1% or non-fat milk and milk products available in store. Lean meats and fish available in store.  Fresh fruits and vegetables available in store.  Brightly-colored fresh fruits and vegetables, available in store.  Affordable fresh fruits and vegetables are available in store. High-quality fresh fruits and vegetables are available in store.  Healthy choices available on restaurant menus, such as main dish salads, low-fat or low-calorie options  Healthier food choices on menus clearly labeled as "healthy".  Menu substitutions to get healthier items are permissable.  It is possible to get nutritional information, such as the fat and calorie content of menu items from information listed on the menu or posted in the restaurant.  Places available to engage in physical activity, including local schools, community recreational centers or gyms, parks, parks with playgrounds, and trails for walking and biking: (Is the destination there & what is the distance)  Availability of places to walk or bike to in the community  How long it would take to walk to the nearest grocery or supermarket; convenience store or small grocery store; school; restaurant;parks; playgrounds; trails;

17. From the Washington 2004 Health Profile Survey – Fact Sheet Series : Nutrition: Most schools provide access to food or beverages in addition to cafeteria foods: 91% of schools have vending machines or a school store, canteen, or snack bar where students can purchase snack foods or beverages. The foods listed in the table at the right are available from these “competitive food sources”: The overall high availability of high-sugar drinks and foods and low availability of fruits and vegetables at schools is at odds with health messages to moderate intake of sugars and choose a variety of fruits and vegetables daily. School Health Profile Healthier options Bottled water96% 100% Fruit juice86% Salty, low-fat snacks including pretzels, baked chips 84% Low-fat baked goods including cookies, crackers, cakes, pastries 64% Fruits or vegetables46% Less healthy options Soft drinks, sports drinks and non- 100% fruit drinks 97% Salty, fat snacks including regular potato chips 80% Chocolate candy72% Other candy75%

18. Evaluation of the State Plan Statewide Assessment Level 3: Ongoing monitoring of long term objectives: nutrition & physical activity; obesity; and prevalence of chronic diseases Washington Vital Records System (death certificates) Washington Behavioral Risk Factor Surveillance System

19. Data Sources: Death Certificate System Annual information on all deaths that occur in Washington, and of Washington residents who die in other states; Estimated to be 99% complete. Cause of death determined by the attending physician or the coroner/ medical examiner. Instruction manuals are provided to physicians, coroners, and medical examiners, as well as local health jurisdictions and others involved in completing and managing death certificates. Causes of death are coded according to the International Classification of Disease, World Health Organization, Ninth Revision (ICD-9) for 1979- 1998; Tenth revision (ICD-10) for 1999 and later.

22. Data Sources: Washington Behavioral Risk Factor Surveillance System (BRFSS) Telephone health survey of chronic diseases, injuries and their risk factors, coordinated by the Center for Disease Control and Prevention (CDC), conducted annually in 50 states since 1986 Self-reported information collected from a random sample of adults living in households with telephones. 2003 data includes 18,000+ records to facilitate county level estimation; 400 interview conducted in Spanish.

23. BRFSS Topics Health status, including general, physical, and mental heath, as well as activity lost because of health conditions. Access to health care, as measured by having health insurance, being able to see a doctor because of cost, and time since last routine checkup. Awareness of selected medical conditions: hypertension, diabetes, and high cholesterol. Nutrition and weight control, including eating of fruits and vegetables and experiencing hunger. Injury control, including use of seatbelts by respondents and children in their household. Tobacco use and alcohol consumption. Social and demographic characteristics, including gender, age, race/ethnicity, marital status, education attainment, employment, household income, weight and height.

24. For example the nutrition module asks how often certain foods are eaten: fruit juice, fruit, green salad & potatoes (other than french fries, fried potatoes or chips) and carrots. A summary index measure is derived from these questions Note: how often an item is eaten is not the same as number of servings Fruits and Vegetables (BRFSS, 2003) These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home. 7.1 How often do you drink fruit juices such as orange, grapefruit, or tomato? 7.2 Not counting juice, how often do you eat fruit? 7.3 How often do you eat green salad? 7.4 How often do you eat potatoes not including French fries, fried potatoes, or potato chips? 7.5 How often do you eat carrots? 7.6 Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?

26. CVD Risk Factors Among Washington Adults, 2001 or 2002

28. Data Sources: Washington Healthy Youth Survey (HYS) Sponsored by OSPI, DOH, DSHS-DASA, and Office of Community Development Health pencil-and-paper survey combining questions from the CDC’s Youth Behavioral Risk Survey (YBRS) and the Monitoring the Future survey Representative sample of schools within a school district Grades 6, 8, 10 and 12 answered questions about safety and violence, physical activity and diet, alcohol, tobacco and other drug use, and related risk and protective factors. Administered in the Fall of 2002 & 2004.

29. Meeting recommended levels of vigorous daily activity: How many of the past 7 days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities? Meeting recommended levels of moderate daily activity: How many of the past 7 days did you do physical activity for at least 30 minutes that did not make you sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping floors? Strength Training: How many of the past 7 days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting? Questions about Physical Activity on the HYS

30. Number of (Non-Diet) Sodas Yesterday Distribution, Grade 102+ by Grade* 2+, Grade 10 by Sex* * P < 0.05

31. Percent Overweight and 2+ Sodas Yesterday * P < 0.05 * *

32. * * 2 or more (non-diet) sodas yesterday and other nutrition- related questions, grade 10 example * * *  5 <5 yes no yes no yes no daily times usually food insecure inappropriate fruit & veggies family dinner dieting (girls) Percent

33. Pregnancy Risk Assessment Monitoring System Joint research project of the Washington DOH & CDC since 1996 Mail/phone survey of ~ 2,000 new mothers, randomly sampled (by race/ethnicity) from birth certificate records, at 2-6 months after delivery. Provides data for the period before, during and shortly after their pregnancy Topics include: prenatal care received, health behaviors during pregnancy, & barriers to receiving prenatal care Also: consumer ideas about pregnancy and early infant care And, finally: intendedness of pregnancy, use of alcohol and tobacco, baby's sleeping position, percent of women breastfeeding, social support, and battering during pregnancy.