ABSTRACT

Childhood obesity is an important public health problem that affects countries in the Americas. In 2014, Pan American Health Organization (PAHO) Member States agreed on a Plan of Action for the Prevention of Obesity in Children and Adolescents in an effort to address the impact of this disorder in the Americas region. The interventions laid out in this regional plan are multi-faceted and require multi-sectoral partnerships. Building on a strong history of successful trilateral collaboration, Canada, Mexico, and the United States formed a partnership to address the growing epidemic of childhood obesity in the North American region. This collaborative effort, known as the Trilateral Cooperation on Childhood Obesity Initiative, is the first initiative in the region to address chronic noncommunicable diseases by bringing together technical and policy experts, with strong leadership and support from the secretaries and ministers of health. The Initiative’s goals include increasing levels of physical activity and reducing sedentary behavior through 1) increased social mobilization and citizen engagement, 2) community- based outreach, and 3) changes to the built (man-made) environment. This article describes the background and development process of the Initiative; specific goals, activities, and actions achieved to date; and opportunities and next steps. This information may be useful for those forming other partnerships designed to address childhood obesity or other complex public health challenges in the region.

Key words
Obesity; child health; Canada; Mexico; United States

Significant advances in medicine and public health have resulted in better disease detection and treatment, decreased maternal and child mortality, improved longevity and economic growth, and better control of infectious diseases in the region of the Americas, resulting in an epidemiological shift from acute, infectious diseases to chronic noncommunicable diseases (NCDs). While infectious diseases are still a significant health problem, especially in Central and South America, NCDs now account for the highest morbidity and mortality in the region (¹1. Pan American Health Organization. Plan of Action for the Prevention and Control of Noncommunicable Diseases in the Americas 2013–2019. Washington: PAHO; 2014. Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=27517&lang=en Accessed on 4 July 2016.
http://www.paho.org/hq/index.php?option=... ). Growing recognition of this transition has resulted in various health initiatives such as the 2011 United Nations Political Declaration on Noncommunicable Diseases (“the Declaration”) (²2. United Nations General Assembly. Sixty-sixth Session, Agenda Item 117. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. New York: UNGA; 2012. Available from: http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf Accessed on 4 July 2016.
http://www.who.int/nmh/events/un_ncd_sum... ), which called for the development and implementation of effective and sustainable approaches to prevent and control NCDs. Two subsequent policy documents, the World Health Organization (WHO) Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (³3. World Health Organization. Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. Geneva: WHO; 2013. Available from: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf Accessed on 4 July 2016.
http://apps.who.int/iris/bitstream/10665... ) and the Pan American Health Organization (PAHO) Plan of Action for the Prevention and Control of Noncommunicable Diseases 2013–2019 (¹1. Pan American Health Organization. Plan of Action for the Prevention and Control of Noncommunicable Diseases in the Americas 2013–2019. Washington: PAHO; 2014. Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=27517&lang=en Accessed on 4 July 2016.
http://www.paho.org/hq/index.php?option=... ), were designed and developed to help meet Declaration goals. The inclusion of NCD goals in the 2030 Sustainable Development Agenda represents yet another milestone for the global NCD movement.

Despite these achievements, little change has been seen over the last decade in the prevalence of childhood obesity, an important risk factor for the development of NCDs. In Canada and the United States, more than one-third of children and adolescents are considered overweight or obese (⁴4. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–14., ⁵5. Roberts KC, Shields M, de Groh M, Aziz A, Gilbert JA. Overweight and obesity in children and adolescents: results from the 2009 to 2011 Canadian Health Measures Survey. Health Rep. 2012;23(3): 37–41.). Mexico has among the highest rates of childhood obesity in the world, with 32% of children ages 6–12 and 35% of adolescents overweight or obese (⁶6. Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T, Villalpando-Hernández S, Franco A, Cuevas-Nasu L, et al. Encuesta Nacional de Salud y Nutrición 2012: resultados nacionales. Cuernavaca, Mexico: Instituto Nacional de Salud Pública; 2012. Available from: http://ensanut.insp.mx/doctos/FactSheet_ResultadosNacionales14Nov.pdf Accessed on 5 July 2016.
http://ensanut.insp.mx/doctos/FactSheet_... ).

The fact that obesity affects alarming proportions of children has mobilized professional organizations, research teams, governments, and civil society to find effective solutions that could stop and reverse the trend. While biobehavioral research continues to explore the underlying mechanisms of obesity, the paradigms of this disorder are being expanded, as highlighted in a special series published by The Lancet in February 2015 (⁷7. Lancet. Obesity Series 2015. 18 Feb 2015. Available from: http://www.thelancet.com/series/obesity-2015 Accessed on 4 July 2016.
http://www.thelancet.com/series/obesity-... ) that took a broader view and focused on a systems approach to tackle this epidemic (⁸8. Horton R. Non-communicable diseases: 2015 to 2025. Lancet. 2013;381 (9866):509–10.).

In 2014, PAHO Member States unanimously approved the Plan of Action for the Prevention of Obesity in Children and Adolescents. The plan encourages countries in the Americas to develop multidisciplinary and multi-sectoral life-course approaches to combat childhood obesity. Such approaches span fiscal policies and regulatory measures to obesity prevention and health promotion programs focusing on physical activity and healthy eating in schools and communities (⁹9. Pan American Health Organization. Plan of Action for the Prevention of Obesity in Children and Adolescents. 66th Session of the Regional Committee of WHO for the Americas. Washington: PAHO; 2014. Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=28890&lang=pt Accessed on 4 July 2016.
http://www.paho.org/hq/index.php?option=... ). While many countries in the region have been implementing these types of measures, there is still a need for better tools, innovative partnerships, and stronger policy interventions.

Canada, Mexico, and the United States have a strong history of trilateral cooperation, particularly on infectious diseases and public health emergencies. Successful initiatives such as the North American Plan for Animal and Pandemic Influenza (NAPAPI), which focuses on infectious diseases, have facilitated sharing of best practices, alignment and development of common approaches, and improvement of response actions during health emergencies. Extending this trilateral cooperation to NCDs leverages existing relationships as well as, in some cases, existing NCD interventions that could be applied across all three countries, and helps address transnational transmission. Like infectious diseases, noninfectious diseases can spread across borders, and transmission is affected by social norms and structures, shared values, and cultural behaviors that may exist across countries. Greater cooperation between governments can capitalize the achievements of one country to benefit others and thus maximize the impact of individual country responses to childhood obesity.

The underlying causes of childhood obesity in all three countries are relatively similar, although the underlying determinants reflect key social, economic, and cultural differences. All three countries have national-level frameworks and action plans to address childhood obesity. These include the National Strategy for the Prevention and Control of Overweight, Obesity and Diabetes (Estrategia Nacional para la Prevención y el Control del Sobrepeso la Obesidad y la Diabetes) in Mexico (¹⁰10. Secretaría de Salud de México. Estrategia Nacional para la Prevención y el Control del Sobrepeso, la Obesidad y la Diabetes. Mexico City: IEPSA, Entidad Paraestatal del Gobierno Federal; 2016. Available from: http://promocion.salud.gob.mx/dgps/descargas1/estrategia/Estrategia_con_portada.pdf Accessed on 4 July 2016.
http://promocion.salud.gob.mx/dgps/desca... ), “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation” in the United States (¹¹11. National Academy of Sciences. Accelerating progress in obesity prevention: solving the weight of the nation. Washington: NAS; 2012. Available from: http://iom.nationalacademies.org/Reports/2012/Accelerating-Progress-in-Obesity-Prevention.aspx Accessed on 4 July 2016.
http://iom.nationalacademies.org/Reports... ), and “Curbing Childhood Obesity: A Federal, Provincial and Territorial Framework for Action to Promote Healthy Weights” in Canada (¹²12. Public Health Agency of Canada. Curbing childhood obesity: a federal, provincial and territorial framework for action to promote healthy weights. Ottawa: PHAC; 2010. Available from: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/framework-cadre/pdf/ccofw-eng.pdf Accessed on 4 July 2016.
http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/... ). The strategies are implemented using different approaches including cross-sector legislative and regulatory initiatives and policies and programs that support healthy eating and physical activity. All three national strategies address similar underlying social determinants, including physical environments of children, access to nutritious foods, consumption of sugar and fat, family empowerment, and physical activity. It is too early to provide concrete measures on the long-term impact of the strategies that have been implemented in any of the three countries.

In response to common challenges related to childhood obesity, such as sedentary behavior and unhealthy diets, and recognizing the value of partnerships and an already proven successful collaboration, the three North American countries began their trilateral initiative on childhood obesity in 2014. The Canada-US-Mexico Trilateral Cooperation on Childhood Obesity Initiative is the first platform in the region to address NCDs by bringing together technical and policy experts, with strong leadership and support from the secretaries and ministers of their national health departments and agencies. This article describes the background and development process of the Initiative; the specific goals, activities, and actions achieved to date; and opportunities moving forward.

CANADA-US-MEXICO TRILATERAL COOPERATION ON CHILDHOOD OBESITY INITIATIVE

Background and process of development

The health secretaries of Mexico and the United States and the health minister of Canada met at the World Health Assembly (WHA) in 2014 and shared their common concerns regarding the increasing prevalence of obesity in their countries. They all emphasized the need to address obesity among children, particularly in early childhood, when the epidemic can be prevented or reversed, and described their national strategies designed to achieve that goal. They agreed to collaborate trilaterally to 1) develop a platform for engagement by technical and policy experts from all three governments, 2) share in-country efforts, and 3) determine where cooperation could best benefit all three countries in the prevention and control of obesity.

In October 2014, officials from the three country health agencies (the Public Health Agency of Canada [PHAC], the U.S. Department of Health and Human Services, and Mexico’s Secretariat of Health [Secretaría de Salud or SALUD]) met in Washington, D.C., for the first time and agreed to a set of principles and objectives (Table 1) to guide a collaboration that would focus on childhood obesity. Subsequently, the working group (known as the Trilateral Working Group on Childhood Obesity) began meeting virtually to present their respective national plans and strategies. Relationships between technical and policy counterparts were forged, in some instances, for the first time. This allowed for more candid and in-depth discussions about opportunities and challenges experienced by each country with respect to their national approaches and future plans.

In May 2015, the group identified a series of activities to deliver on the mandate provided by health ministers. These included developing the organizational mechanisms for collaboration to facilitate sharing of research findings and the best practices and lessons learned from each country.

Goals, activities, and actions achieved to date

Exchanges among the three countries were carried out through technical meetings and teleconferences, mostly focused on learning and understanding the different national strategies, interventions, multi-sectoral approaches, and strategic partnerships under way to address childhood obesity. Countries shared success stories and highlighted a few programs, including “Let’s move!” (United States); “Chécate, Mídete y Muévete” (Mexico); and “Multisectoral Partnerships to Promote Healthy Living and Prevent Chronic Disease” (Canada). Knowledge was shared through the creation of both a technical and a policy committee, each of which had representatives from the three countries. Both of these committees continue to report on their progress regularly.

The group agreed to focus the collaboration on efforts to increase levels of physical activity and reduce sedentary behaviors by emphasizing increased social mobilization and citizen engagement, community-based outreach, and changes to the built environment. Once these activities were identified, they were discussed at two different meetings: 1) a technical workshop (the “Public Health Trilateral Cooperation Meeting”), held in Mexico City in July 2015, and 2) a technical meeting, held in Washington, D.C., in October 2015.

While the factors that drive the obesity epidemic are complex, imbalance between caloric intake and energy expenditures contributes to the disorder. Moreover, evidence-based studies indicate that physical activity can play an important role in the prevention of childhood obesity and contributes to a wide range of other positive health outcomes (¹³13. Janssen, I, Allana GL. Review Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act. 2010;7(40): doi: 10.1186/1479-5868-7-40.
https://doi.org/10.1186/1479-5868-7-40... ).

Therefore, once the countries agreed to focus on improvement of physical activity as a common theme, a discussion of potential interventions took place at the trilateral technical workshop in Mexico City in July 2015.

Public Health Trilateral Cooperation Meeting

The technical workshop held in Mexico City included several working groups and panel discussions. Based on the meeting output it was decided that the initial objectives of the trilateral collaboration would be 1) promoting walking and 2) enhancing opportunities for physical activity by improving access to opportunities for exercise, potentially in partnership with a common community-based organization operating in all three countries. The objective of this approach would be to provide opportunities to decrease sedentary behavior and increase physical activity among children and their family members and caregivers through an intergenerational approach. Thus, the conclusion of the technical workshop in Mexico was an agreement to work on the reduction of sedentary behavior by promoting walking and other community-based activities within the respective national contexts. The discussion in Mexico also defined supportive interventions (Table 2).

Technical meeting

As a follow-up to the technical workshop, in October 2015 country representatives met in Washington, D.C., to define the priority collaborative activities. These included 1) enhanced programming on physical activity across all three countries, specifically intergenerational physical activity, engaging families to be physically active together as the mechanism, and 2) thematic “Program Forums” delivered via teleconference/videoconference to allow for open discussions on key program and operational topics such as the effects of sedentary behavior and the built environment on childhood obesity, and the implementation of multi-sectoral partnerships for healthy living.

Expected short-term outcomes of these two activities include developing strong, family-based physical activity programs implemented in each country, operating under similar goals and principles, and adapted to each country’s specific national context. Longer-term outcomes include demonstrating North American joint cooperation in addressing childhood obesity by improving physical activity levels among children and their families. Results of these initiatives were reported at a trilateral senior officials’ meeting held on the margins of the 2016 World Health Assembly in Geneva.

Opportunities and next step

Childhood obesity is a top public health priority for all three countries and the global community given the links to NCDs, disability and premature death. While there is some evidence that childhood obesity rates are stabilizing in North America, this stabilization is not consistent among all age groups and remains at unacceptably high levels. To reduce childhood obesity rates, sustained, intensive, and scaled-up action is required.

As the trilateral collaboration matures and results of initial activities emerge, further opportunities for collaboration and cooperation will evolve. Through established networks and relationships, other opportunities will develop for moving beyond the initial focus on increasing physical activity into other areas where there is value-added for all three countries. Such areas could include data surveillance, shared public health interventions based on emerging evidence, and partnerships with other sectors.

Data surveillance

Opportunities exist for trilateral partners to share expertise and experience on how to incorporate emerging evidence into surveillance systems and public health interventions. Areas for surveillance that can be explored trilaterally include how to incorporate nontraditional sources of information into public health surveillance, such as data on physical activity and food consumption from portable electronic devices and smart phone applications. Mobile health applications could be developed to reach children and youth in all three countries considering the many shared social and cultural characteristics that manifest in their use of social media and other platforms of communication.

As highlighted by the WHO Commission on Ending Childhood Obesity, taking a life-course approach to prevention and healthy living may influence obesity rates. A growing body of evidence suggests that prenatal health, the health of the mother and father, and the family environment can influence a child’s risk for developing obesity. How to enhance surveillance systems and develop public health interventions to incorporate such an approach is an emerging area. Trilateral innovation in this area has the potential to inform dialog at the global level.

Conclusions

In the area of partnerships, opportunities exist to explore extending trilateral cooperation to other sectors involved in addressing childhood obesity and to champion collaboration between other sectors outside of national governments. By leveraging respective domestic networks and stakeholder relationships, Canada, Mexico, and the United States can link organizations with strong track records for contributing to prevention and health promotion in their respective countries, including those from the nongovernmental, academic, and private sectors.

Trilateral Working Group on Childhood Obesity

In addition to the authors, members included Shavon Arline-Bradley (United States), Jamie Baker (Canada), Tammy Bell (CA), Karla Bonilla (MX), Sharon Boyd (US), Kirby Bumpus (US), Martha Caballero (MX), Abigail Campbell (CA), Janet Collins (US), Hilda Davila (MX), Vivian Ellis (CA), Deborah Galuska (US), Rodney Ghali (CA), Chad Hartnell (CA), Guadalupe Iglesias (MX), Eduardo Jaramillo (MX), Alejandra Juarez (MX), Gabrielle Lamourelle (US), Maya Levine (US), Robin McKinnon (US), Allison O’Donnell (US), Laura Olsen (US), Lucero Rodriguez (MX), Diego Sanchez (MX), Ranu Sharma (CA), Andrew Shell (US), Richard Troiano (US), Dylan Upper (CA).

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