July 2006

Signature Story: Turning the Tables

Featuring The American Dietetic Association

By Rachel Crippin Clark

Emma* and Tyler * are two 10-year-olds who share a love of television and playing computer games. Both have busy, but loving, parents who work outside the home, so the children's meals usually consist of frozen processed food that they themselves can heat up in the microwave or stick in the oven. They live in urban areas that lack safe recreational opportunities and are under strict instructions to come straight home from school.

Both children are at risk for being overweight. However, Emma's fifth-grade class just started a new nutrition and cooking program sponsored in part by the American Dietetic Association (ADA). Every week a local high school student visits Jessica's classroom with a portable kitchen to help teach students fun ways to cook healthy foods … from smoothies to stir-fry and muffins in the microwave.

Will Emma escape the growing trend among her peers of becoming obese at a young age? It may be too soon to tell, but the ADA is determined not to let the daunting scope of the country's obesity epidemic get in its way. To that end, the Chicago-based association has identified obesity as one of its five major priority areas and is working tirelessly on a number of fronts to turn the tables on a nationwide health crisis. It's not a problem with easy solutions, but one that touches just about every aspect of the nearly 65,000-member professional association … and millions of people across the country just like Jessica and Tyler.

Not your Everyday Challenge

Last year, United States Surgeon General Richard Carmona identified obesity as the "leading public health problem in America ." Sixty-five percent of Americans — including nine million children — are overweight or obese, and more than 365,000 die of obesity-related diseases each year.

More serious than smoking in terms of chronic illness and health spending, obesity contributes to heart disease (the nation's biggest killer), diabetes, stroke and some types of cancer. In fact, it's believed to contribute to over 30 adverse health conditions. In dollars and cents, the journal Health Report estimates that the national cost of treating obese people's health problems is close to $100 billion.

What's more — the incidence of obesity is growing at alarming rates. Adult obesity has increased by more than 60% in the last twenty years. Even more disturbing is that obesity rates have doubled among children and tripled among adolescents since 1980. Those who become obese at a young age are even more at risk for developing chronic illnesses that may reduce the length and quality of their lives.

The scope of the problem is huge, but ADA 's stance is that it doesn't mean there isn't important work that can, and should be, done. "Certainly something like obesity can't be solved by the ADA or even our 65,000 members," acknowledges Ronald Moen, ADA chief executive officer. "Our role is to serve our members and inspire them to be active in being part of the solution."

To Dream the Impossible Dream?

Though the ADA had been targeting obesity for years, the issue was officially identified as one of five priority areas back in 2000 as part of the association's strategic planning process. That process, which takes place every 4-5 years, involves a comprehensive environmental scan to ensure that the organization as a whole is properly aligned with the state of dietetics, its members, health care and society overall.

Overseen by ADA 's House of Delegates, input on emerging trends affecting dietetics is solicited from House members, as well as members at-large. Staff is responsible for pulling together input, and then an outside futurist assesses and validates the findings. Trends are then submitted to the Board of Directors' Strategic Planning Task Force to serve as a foundation for reviewing and/or updating the association's mission, vision and goals.

Based on member feedback, obesity was an obvious selection for the priority list. In fact, it ranked as the number one issue, though the Board currently does not rank its five priority areas. Obesity has since been reaffirmed as a target area.

In 2003, the ADA Board formed an Obesity Task Force charged with coordinating efforts on the obesity issue throughout ADA and its many organizational units, as well as identifying new opportunities and related issues. That nine-member task force reports back to the Board and represents a diverse cross-section of ADA membership, including academia, research, government and practitioners, as well as a staff partner.

According to Moen, Board-appointed task forces are common at ADA and allow the association to take a fresh look at issues with the assistance of members who are not otherwise consumed with other responsibilities within the organization.

The Obesity Task Force, in particular, was effective in tying together a lot of moving parts on the obesity issue within the large association. After all, ADA has 29 dietetic practice groups (DPGs) and 50 affiliated state dietetic associations plus the District of Columbia, Puerto Rico and the American Overseas Dietetic Association. Within the 50 state groups, there are approximately 230 district associations.

"I liken (the ADA) to the United States because it has so many different layers of organizational units such as DPGs, geographical units, practice units, as well as a diverse membership in which everyone has a unique niche," says Molly Gee, MEd, RD; chair of ADA's Obesity Task Force and project leader for the Baylor College of Medicine. "There are so many intricate pieces." 

To Achieve an Impossible Dream

How exactly has the ADA tackled the obesity problem? It's not been one step at a time.

"I'd call it ‘multiple steps at a time'," says Moen. "There is no one single solution." Obviously, a large part of ADA's efforts revolve around educating its members on obesity issues and providing them with skills and resources to be the most effective they can be in their jobs. But a large part of serving its members centers on attacking the problem on a public policy level, as well as reaching out to fellow health care professionals, the media and the general public with expert advice and information.

As a result, the association has developed a broad-based set of programs and initiatives. The list (see sidebar, p. x) is divided into initiatives on the family, community, and national level, as well as those targeting ADA members.

"This can be a very frustrating issue for dietitians because their patients have high expectations, varying levels of motivation, and there's just too much confusing information out there for patients to digest," says Rebecca Reeves, DrPH, RD, FADA; ADA president, and at Baylor College of Medicine, assistant professor of medicine & managing director of the Behavioral Medicine Research Center. "As a result, there is an extremely broad landscape for our efforts because we have so many angles to hit."

Members, too, tend to agree there is no single solution. Of all of ADA's activities on the obesity issue, "I'd be hard pressed to say that one is more important than the other," says Cathy Nonas, MS, RD, CDE, CDN; director of obesity and dietetics programs at North General Hospital in New York City. "They all add up. Obesity is a problem on every level and so it needs to be attacked on every level. I'm impressed with the amount of work and the quality of work that ADA is doing."

"Obesity is a multi-factorial problem, so you've got to hit

it at multiple levels. You have to have all the players on board," concurs Christine Rosenbloom, PhD, RD, LD; ADA member and professor & associate dean for academics at Georgia State University. "ADA is well-positioned to deal with this because it's a huge organization, it's well-respected, and has good relationships with the food companies, government and related associations."

ADA Leadership

Indeed, because obesity is so prevalent and is a factor in so many diseases, there are many different associations, government entities and private businesses that are working to combat the disease. Health associations such as the American Heart Association and American Diabetes Association are active, and there even is the American Obesity Association — founded in 1995 — focused on changing public policy and perceptions about obesity.

The number of groups working to combat the disease is an asset, not a challenge. "(Beating the obesity epidemic) is going to take all of us working together," says Reeves. "That means ADA, other health associations, food companies, quick-serve restaurants, schools, government, media, and consumers." In fact, the ADA is actively partnering with several different organizations on obesity initiatives.

Yet, the association has many assets that make it a respected leader in the obesity challenge. First, the association is guided by a reliance on sound science and evidence-based practice. "Scientific evaluation is at the heart and soul of everything that we do," says Moen. While that leads to a solid knowledge base from which its members can benefit, it also creates a positive reputation with stakeholder groups.

That reputation has led consumer media outlets to rely heavily on the ADA for expert advice and commentary on a whole host of food and nutrition-related topics. As a result, 30 members serve as volunteer spokespeople in the nation's largest media markets and are well-positioned to serve as leading experts on the obesity issue.

In addition, ADA members are uniquely qualified to treat overweight and obese patients at all stages of their life span and in a myriad of environments. "One of the things that happens is we often become the professionals who obese people see the most," says Nonas. "Dietitians almost always triage the patient, making decisions about when the person needs to see a doctor because of a certain symptom, or if they need to see a counselor for some psychological issue coming into play."

In 2005, the Surgeon General praised ADA members for their important role in helping translate scientific research for their patients. In a supplement to the ADA's Journal, Carmona said, "Health literacy is the ability of an individual to access, understand and use health-related information and services to make appropriate health decisions. Thank you so much for all you're doing to improve the health and health literacy of all the people of our great nation."

Funding for Community Programs

Getting back to Emma and Tyler … the alarming increase in childhood obesity has led the ADA to pay particular attention to health of the nation's young people. First, there are immediate benefits when children improve their diet and fitness level, both in terms of their health, school performance and self-esteem. In addition, research shows that healthy behaviors learned in childhood and adolescence carry over into adulthood.

It was with these issues in mind that the ADA Foundation (ADAF) partnered with the General Mills Foundation and the President's Challenge on a program called General Mills Champions for Healthy Kids. This initiative provides micro-grants to community-based groups to help them improve youth nutrition and fitness in their areas.

"This initiative is especially exciting because it is a seed-money concept benefiting many different organizations across the country," says Moen. "It is designed to stimulate what we hope are best practices, and we are currently looking at how

to take it to the next level."

Fifty grants of up to $10,000 each are awarded once a year to non-profit organizations. While grants are funded by the General Mills Foundation, "Staff time accounts for (ADAF's) largest and most significant contribution to the project," explains Mary Beth Whalen, Vice-President, Executive Director, ADA Foundation. "Our staff is involved in the coordination of application reviewers, communication with applicants, promotion of final awards, and collection of evaluation information." Among other things, reviewers make sure a RD is participating on the program.

These grants are especially helpful since lack of funding in schools and communities has hampered nutrition and fitness education in many areas. For example, the hands-on nutrition class that Emma  took is an actual class being offered in Hickman Mills School District in Kansas City, Missouri as a result of a Champions grant. This district — located in a low-income neighborhood with many minority students living in single-parent households — has an estimated 40% of students overweight or at risk for overweight.

With the grant, Nutrition Education Coordinator Grennan Sims, RD, LD (also an ADA member) took an existing high school mentor program and enhanced it with the Whiz, Zip & Zap nutrition education program created by a company called Nutra-Net. Now, approximately 26 mentors visit fifth grade and kindergarten classes to facilitate nutrition education and cooking lessons.

According to Sims, the program has been a great success due to the professional materials and expertise of the Nutra-Net program, as well as the positive influence of older kids from the district. The older kids get quality training, and the younger kids get good role models and a cookbook that they can take home to practice with. That's key because "twenty years ago, kids could go home, play outside, run around with friends, ride bikes, etc," says Sims. "But crime is a problem and many kids go home and have to stay inside…usually to watch TV or play video games."

Another successful program is the "Health Teens!" program run by a Children's Memorial Hospital satellite site here in Chicago. Developed thanks to a Champions grant, the program is run out of a full-functioning ambulatory clinic in Uplift Community School.

The middle school's students who enter the clinic are screened no matter the reason for their initial visit. Any child who has a body mass index (BMI) greater than the 85th percentile is offered the program, which consists of 5-6 individualized visits with a nurse practitioner, a registered dietitian and a social worker. The goal is to help them make small attainable nutrition and fitness goals.

The program is unique in that "we do not talk specifically about weight with the students unless they bring it up. The main focus in on making healthy lifestyle choices," says Meghan Kostyk, Nurse Practitioner with Children's Memorial Hospital, who works with an RD on the program. Some students have tried "dieting" without success, some don't know where to start and some do not even view themselves as being overweight. "This group is especially challenging as we do not want to create any body image issues that were not there previously."

Since its inception in 2002, the Champions Grants Program has invested more than $6 million in youth nutrition and fitness programs that have served more than 100,000 children across the country. All of the programs that have received a Champions grant continue to operate today, and many groups reported that they received another grant because of the Champions grant program.

Exercise Plays an Important Role

It seems every day that someone releases a new book or DVD touting a new diet or exercise program. Consumers are constantly bombarded by new information on weight loss, and it often is conflicting, or not exactly based on sound science or healthy practices. As a result, consumers either get frustrated by lack of results, gain weight again when they end the program, or compromise other aspects of their health in the process.

For that reason, the ADA is now working with the American College of Sports Medicine (ACSM) to establish specific criteria for what constitutes an effective weight management program. Recognizing the essential role of both food and exercise in weight management, the criteria will be simple enough for consumers to follow and will serve as an important tool for ADA practitioners.

"What motivated us on this partnership is that once people's eyes get glazed over, that's their excuse (for failing to start or keep up with a health weight management program)," says Gee. "There's so much information out there and it's too hard for them to keep up with."

This initiative is part of a wider partnership between ADA and ACSM that takes advantage of their respective expertise in nutrition and exercise science. It is a natural alliance, though coordinated efforts have been added on a step-by-step basis. Rebecca Reeves just presented a nutrition session at ASCM's annual meeting, and ASCM will return the favor with an exercise session at ADA's upcoming meeting. Also, each organization is drafting a position paper on their part of expertise, with the plan that the other group will officially endorse theirs.

Member Education

On the professional development side, ADA has been busy helping members stay on top of the constant flow of obesity information. This is one of dietitian's biggest challenges, according to Reeves. "They've got a responsibility to stay on top of a wealth of ever-changing information."

Following several highly successful workshops that awarded certificates in both adult and child weight management, ADA decided in 2003 to create a Weight Management DPG. Its primary goal is to concentrate all of the latest information including treatment, legislation, drugs, and metabolic aspects in one place. Knowledge is shared via its website, a listserv and periodic newsletters, as well as a first-ever symposium planned in conjunction with ADA's next annual meeting.

The Weight Management DPG is the fastest growing of any of ADA's 29 groups and now has over 4,000 members. As is the case with ADA's other DPGs, it is managed by a team of volunteer officers and a staff liaison.

Another high-impact tool for members was a special obesity supplement to the ADA's Journal in 2005. While the Journal frequently features topics relating to obesity and weight management, this 136-page resource tied a wealth of information in one place. Another goal was to "encourage the development of innovative and effective approaches to successful long-term management of this devastating disease," according to guest editor Sachiko T. St. Jeor, PhD, RD.

Also, in an unprecedented outreach effort, the supplement was also mailed to 8,000 physicians throughout the country and offered them Continuing Medical Education credit for the first time. Recognizing doctors' important role in the weight management process, the outreach served to share dietetic professionals' evidence-based knowledge and expertise with partners in their process.

Getting Treatment Covered

A significant challenge to fighting obesity is that treatment is not commonly reimbursable through many health insurance plans. While obesity has been defined as a distinct disease by many top health organizations, many insurance companies still consider it a lifestyle choice and not a disease for reimbursement purposes. Third-party payers generally cover treatment of conditions caused by obesity, but there is little reimbursement for prevention or treatment of obesity itself.

One of the exceptions is Blue Cross Blue Shield of North Carolina. The North Carolina Dietetics Association worked with the insurance company to start covering obesity treatment in 2004. Recognizing this important opportunity to demonstrate positive long-term effects, the ADA national headquarters is now partnering with BCBS to evaluate the health, utilization and economic outcomes of this coverage. This is the first of a three-year initiative that involves ADA's volunteer Research Committee, as well as its staff Director of Scientific Research.

The Fight has Just Begun

Today, obesity remains a significant threat to our nation's health. Yet, the efforts of ADA have had impressive and far-reaching impact in helping millions of Americans, and the fight is not even close to being over.

"We're not saying our efforts are going to be the ‘be all, end all.'" says Gee, chair of the Obesity Task Force. "You have to start somewhere."  Indeed, there are thousands of dietitians around the country giving their patients the same good advice … patients just like Emma or Tyler.

For fifth grade Emma at Hickman Mills, the nutrition class has definitely been a huge hit. Perhaps more importantly, besides being such a popular course for the kids, the program has long-term benefits. Shawna Millentree, one of the school's 5th grade teachers, says, "Its effects will be far reaching, beyond what we can measure now."

Emma's classmate, Jameka, says, "I liked making the food, but I really loved eating it, too. I'm really happy that you actually took the time to help us."

Emma wrote a letter to Sims, the district's nutrition coordinator, after the class was over. "I liked this class because ... the teens reminded us what things were in the food we were making." With that type of education and knowledge, thanks to ADA, it's likely that Emma will not be like nine million of her peers; she has learned how to beat the obesity trend. 

*Children's names are hypothetical, based on real-life programs and scenarios.

SIDEBAR:

The ADA + ADA Foundation

The American Dietetic Association's mission is to lead

the future of dietetics. ADA and its nearly 65,000 members strive to be the most valued source of information and services related to food and nutrition.

The ADA Foundation — which funds education and research projects to improve the public's nutritional health, the Commission on Dietetic Registration — is the credentialing agency for nutrition professionals, and the Commission on Accreditation for Dietetics Education — which accredits undergraduate and graduate-level education programs.

ADA is led by a 17-person Board of Directors. The dietetics profession is governed by a 130-member House of Delegates.

SIDEBAR:

Weight Defined

According to the Institute of Medicine, obesity is defined as an excess of body fat, whereas overweight refers to

an excess of body weight that includes fat, bone, and muscle. Globally, a Body Mass Index (BMI) of 25 to 29.9 for adults is considered overweight; a BMI of 30 or more, obese.

—        American Dietetic Association Complete Food & Nutrition

            Guide – 2nd edition

SIDEBAR:

ADA Programs + Initiatives

The ADA and ADAF have developed a broad-based set of programs and initiatives to tackle obesity including:

Family Focus

•           Developed a screening tool to assist families in assessing their nutrition and physical activity levels.

•           Conducted a study to identify family behaviors and attitudes that contribute to unhealthy children's weights.

•           Provide nutrition information for a non-commercial Web site targeting tweens, in conjunction with several organizations such as the International Food Information Council.

•           Evaluating the health, utilization and economic outcomes of new obesity coverage through an insurance plan in North Carolina.

•           Produced a user-friendly guide for families to help children achieve and maintain healthy weight, in conjunction with health insurance company Wellpoint.

Community Focus

•           Supports nutrition and physical activity events in parks and recreational facilities through the Hearts N Parks program, in conjunction with the National Recreation and Parks Association.

•           Partners with the General Mills Foundation and the

President's Challenge to award grants to community organizations helping youth develop good nutrition and fitness habits.

•           Participates in a national collaborative effort targeting adolescent health.

Member Professional Development

•           Published numerous position papers on weight

management.

•           Launched two certificate programs on adult and child weight management.

•           Created a weight management practice group to facilitate the sharing of the latest knowledge and practical skills.

•           Offers many sessions on obesity/overweight topics at annual meeting, as well as tele-seminars.

•           Published two books and a client education booklet on obesity.

•           Working to establish criteria for assessing healthy

weight management programs.

National Planning

•           Developed a concept paper that outlines public policy principles and strategies that guides testimony and

positions on legislative issues.

•           Active participant in the Healthy School Summit focused on creating a healthy nutritional environment at schools.

•           Exploring an alliance of organizations that would promote behavioral change as one of the necessary factors in achieving/maintaining healthy weight.

Rachel Crippin Clark may be reached at (847) 832-0699 or

rcclark@wideopenwest.com.