Background

1. Preventing Childhood Obesity: Health in the BalanceRoss C. Brownson, Ph.D.St. Louis University School of Public HealthAPHA ConferenceWashington, DC

2. Background • Congressional request (2002) • Sponsors: CDC, NIH, ODPHP, RWJF • 19-member multidisciplinary committee • Task: prevention-focused action plan • 24 months

3. JEFFREY P. KOPLAN (Chair), Emory University DENNIS M. BIER, Baylor College of Medicine LEANN L. BIRCH, Pennsylvania State University ROSS C. BROWNSON, St. Louis University JOHN CAWLEY, Cornell University GEORGE R. FLORES, The California Endowment SIMONE A. FRENCH,University of Minnesota SUSAN L. HANDY, University of California, Davis ROBERT C. HORNIK, University of Pennsylvania DOUGLAS B. KAMEROW, RTI International SHIRIKI K. KUMANYIKA, University of Pennsylvania BARBARA J. MOORE, Shape Up America! ARIE L. NETTLES, University of Michigan RUSSELL R. PATE, University of South Carolina JOHN C. PETERS, Procter & Gamble Company THOMAS N. ROBINSON, Stanford University CHARLES ROYER, University of Washington SHIRLEY R. WATKINS, SR Watkins & Associates ROBERT C. WHITAKER, Mathematica Policy Research Committee on Prevention of Obesity in Children and Youth

4. An Epidemic of Childhood Obesity • Since the 1970s, obesity prevalence has • Doubled for preschool children aged 2-5 years • Doubled for adolescents aged 12-19 years • Tripled for children aged 6-11 years • More than 9 million children and youth over 6 years are obese • Reflect similar trends • U.S. adults • Adults and children internationally

5. Terminology • Obesityrefers to children and youth who have a body mass index (BMI) equal to or greater than the 95th percentile of the age- and gender-specific BMI charts of the Centers for Disease Control and Prevention (CDC) • In most children, BMI values > 95th percentile are known to indicate elevated body fat and to reflect the presence or risk of related diseases No BMI-for-age references for children < 2 years

6. Trends in Childhood Obesity Prevalence Prevalence (%) SOURCE: Ogden et al.. J Am Med Assoc. 2002; 288(14):1728-1732.

7. Physical Health Glucose intolerance and insulin resistance Type 2 diabetes Hypertension Dyslipidemia Hepatic steatosis Cholelithiasis Sleep apnea Orthopedic problems Emotional Health Low self-esteem Negative body image Depression Social Health Stigma Negative stereotyping Discrimination Teasing and bullying Social marginalization Implications for Children and SocietyPhysical, social, emotional health consequences

8. Social Norms and Values • Primary and Secondary Leverage Points • ● Food and Agriculture ● Education ● Media • ● Government ● Public Health ● Health Care • ● Land Use and Transportation • ● Leisure ● Recreation Behavioral Settings ●Home ●School ●Community Genetic, Psychosocial, and Other Personal Factors Food and Beverage Intake Physical Activity Energy Expenditure Energy Intake Energy Imbalance Obese Children & Youth Framework for Understanding Obesityin Children and Youth

9. Energy Balance Energy intake = Energy expenditure For children, maintain energy balance at a healthy weight while protecting health, growth and development, and nutritional status

10. Review of the Evidence • The committee strongly endorsed an action plan based on the best available evidence instead of waiting for the best possible evidence • Integrated approach to the available evidence • Limited obesity prevention literature upon which to base recommendations • Parallel evidence from other public health issues • Dietary and physical activity literature

11. Serious nationwide health problem requiring a population-based prevention approach Goal is to create supportive environments that promote energy balance – healthful eating behaviors and regular physical activity Societal changes needed at all levels involving multiple sectors and stakeholders Key Conclusions

12. Leadership Evaluation Resources Efforts at all levels Change in societal norms What is Needed? Healthful Eating Behaviors and Physical Activity are the Norm Obesity Prevalence Increasing

13. Changing Social NormsPublic Health Precedents • Tobacco control • Underage drinking • Highway safety • Use of seatbelts and child car seats • Vaccines • Fluoridation

14. Key Stakeholders to Involve Children, youth, parents, families Child- and youth centered organizations; community-based organizations Community development and planning Employers and work sites Food and beverage industries, food producers, advertisers, marketers, and retailers Foundations and nonprofit organizations Government agencies and programs Health-care providers and delivery systems; professional societies Health-care insurers, health plans, and accrediting organizations Mass media, entertainment, recreation, and leisure Industries Public health professionals Recreation and sports enterprises Researchers Schools, child care programs

15. Action Plan for Obesity Prevention • National Public Health Priority • Healthy Marketplace and Media Environments • Healthy Communities • Healthy School Environment • Healthy Home Environment

16. National PriorityGovernment at all levels to provide coordinated leadership • Federal coordination • Program and research efforts to prevent childhood obesity in high-risk populations • Resources for state and local grant programs, support for public health agencies • Independent assessment of federal nutrition assistance programs and agricultural policies • Research and surveillance efforts

17. Healthy Marketplace and Media • Healthful products, expand meals, create physical activity opportunities • Labeling • New advertising and marketing guidelines • Multi-media and public relations campaign

18. Healthy Communities • Mobilize communities • Build diverse coalitions • Develop and evaluate community programs • Address barriers for high-risk populations • Enhance built environment • Revise city planning practices • Improve opportunities for physical activity • Prioritize capital improvement projects • Improve access to healthful food

19. Examples of Community Programs • Kids Off the Couch – Modesto, CA • Provides information and tools to parents and caregivers • Feet First – Seattle, WA • Neighborhood assessments of potential for physical activity- walking, bike paths • Edible Schoolyard – Berkeley, CA • 6-8 graders participate in school garden seed-to-table approach (ecoliteracy) • Safe Routes to Schools • Education, engineering, and encouragement approaches to walk- and bike-to-school programs

20. Healthy Schools • Develop nutritional standards for all school foods • Increase physical activity to at least 30 minutes/day • Enhance curriculum • Reduce in-school advertising • Utilize school health services • Provide individual student BMI assessments to parents • Bolster after-school programs • Use schools as community centers

21. Healthy Homes • Exclusive breastfeeding first 4-6 months • Provide healthful foods - consider nutrient quality and energy density • Encourage healthful decisions re: portion size, how often and what to eat • Encourage and support regular physical activity • Limit recreational screen time to < 2 hours/day • Parents should be role models • Discuss child’s weight with health care provider

22. School Food Develop nutritional standards for all school foods • Currently • Minimal federal regulations beyond school meal programs; many states and localities have adopted stricter standards • Proposed • All foods sold and served in schools meet nutritional standards – includes contents of vending machines, school stores, fundraisers • State education agencies and local school boards should adopt and implement these standards or develop stricter standards for their local schools

23. Physical Activity Current recommendations – 60 minutes of moderate to vigorous physical activity each day • At least 30 minutes at school • Currently • Reduced PE classes, reduced participation in PE particularly in high school students • Proposed • Expand intramural and extramural options • Innovative, varied, and engaging activities • Promote walking and biking to school

24. Walking and Biking to School • 1969– 48% of all students walked or biked, among those within a mile 90% walked or biked • 1999– 19% walked and 6 % biked at least once a week • Current barriers • Schools sited at distances from neighborhoods • Parental concerns about safety, time, weather • Lack of sidewalks, safe street crossings • Recommendations • Promote walking/biking to school programs • Evaluate interventions

25. School Environment • Promote consistent school environment with healthy choices • Other areas to address • Increase and enhance wellness curriculum • Reduce advertising in schools • Engage school health services • Annually assess student BMI and provide information to parents • Enhance after-school programs • Use schools as community centers • Evaluate school programs and policies

26. Summary • Epidemic of childhood obesity is upon us • Many sectors need to be mobilized to make positive changes • Comprehensive approaches are key • Several aspects of the built environment are likely to be key • School & community • Should rely in existing evidence-based strategies and new, innovative approaches should be evaluated • It will take years to decades to reverse this trend

27. Preventing Childhood Obesity: Health in the BalanceTo order:www.nap.eduExecutive summary available for free downloadFor more information: www.iom.edu/obesity