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Preventing Childhood Obesity: Health in the Balance 4 A National Public Health Priority Although the general public has become increasingly aware of the personal health consequences of obesity, what may not yet be generally apparent is the public health nature of the obesity epidemic and the consequent need for population-based approaches to address it. Obesity prevention should be public health in action at its broadest and most inclusive level, as is true for the ongoing efforts to prevent youth from smoking. For example, local communities are passing ordinances that ban or limit cigarette vending machines, schools and community youth organizations are discouraging or banning smoking, states are passing excise taxes to raise tobacco prices, the federal government is providing national leadership and the resources for research and programs, and the private sector is restricting smoking in workplaces (Box 4-1) (Economos et al., 2001; IOM, 2003). In addition, a broad, complementary, and continuing campaign aimed at reducing adult smoking continues to be conducted. The 2004 Surgeon General’s report on tobacco use emphasized that “a comprehensive approach—one that optimizes synergy from a mix of educational, clinical, regulatory, economic, and social strategies—has emerged as the guiding principle for effective efforts to reduce tobacco use” (DHHS, 2004). A similarly broad-based approach is needed for childhood obesity prevention. Across the country these efforts are beginning. As discussed throughout this report, current efforts range from new school board policies and state legislation regarding school physical education requirements and nutrition standards for beverages and foods sold in schools to community initiatives to expand bike paths and improve recreational facilities.
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Preventing Childhood Obesity: Health in the Balance BOX 4-1 Comprehensive Efforts to Address Public Health Concerns Highway Safety: Federal government: Safety regulations for new vehicles; highway design and safety regulations; establishment of the National Highway Traffic Safety Administration; state and community grant programs; research funding State and local governments: Highway safety offices; primary enforcement of safety belt laws; alcohol-impaired-driving laws; requirements for licensing and driver education; motor vehicle inspections Public support and advocacy: Citizen advocacy groups (e.g., Mothers Against Drunk Driving) Research Media campaigns Education: Driver education; parent education regarding safety seats Tobacco: Federal government: Airline smoking ban; warnings on tobacco packages; research funding; Surgeon Generals’ reports; establishment of the Office on Smoking and Health State and local governments: Excise taxes, laws that establish smoke-free workplaces and public locations Public support and advocacy: Grassroots efforts to prevent exposure to second hand smoke; community coalitions (e.g., ASSIST) Research Media campaigns Education: School-based programs NOTE: This box denotes only selected examples of the multiple approaches used to address each public health problem. SOURCES: IOM, 1999, 2003; Economos et al., 2001. Parallel and synergistic efforts to prevent adult obesity, which will contribute to improvements in health for the U.S. population at all ages, are also beginning. Grassroots efforts made by citizens and organizations will likely drive many of the obesity prevention efforts at the local level and can be instrumental in driving policies and legislation at the state and national levels (Economos et al., 2001). A policy analysis by Kersh and Morone (2002) shows that three of the seven common triggers for strong public action in response to a public health problem are beginning to be activated with respect to the U.S. obesity epidemic: social disapproval that shifts the social norm, evidence-based medical research, and self-help movements for overweight and obese individuals. Other triggers that have worked successfully for public health problems such as tobacco, alcohol, and illicit-drug use (a widespread coordinated movement or campaign; fear of problem-related behaviors or re-
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Preventing Childhood Obesity: Health in the Balance lated culture, such as the drug culture; coordinated interest group advocacy; and targeting of groups or industries contributing to the problem) are not yet fully in place for obesity prevention or may not be relevant to this issue (Kersh and Morone, 2002; Haddad, 2003). The additional impetus that is needed is the political will to make childhood obesity prevention a national public health priority. Effective prevention efforts on a nationwide basis will require federal, state, and local governments to commit sufficient resources for surveillance, research, programs, evaluation, and dissemination. As the nation focuses on obesity as a health problem and begins to address the societal and cultural issues that contribute to excess weight, poor food choices, and inactivity, many different stakeholders will need to make difficult trade-offs and choices. Industries and businesses must reexamine many of their products and marketing strategies. Governments at the local, state, and national levels must consider this issue in setting priorities for programs and resources. Schools need to ensure that consistent messages regarding energy balance are a basic part of the school environment. Community organizations and numerous other stakeholders must examine the ways in which local opportunities for a healthful diet and physical activity are made accessible, available, affordable, and acceptable to children, youth, and their parents. Families need to make their homes more conducive to a healthful diet and daily physical activity. Many of these changes will be challenging because they present Americans with difficult trade-offs. However, as institutions, organizations, and individuals across the nation begin to make changes, societal norms are likely to change as well; in the long term, we may become a nation where proper nutrition and physical activity that support energy balance at a healthy weight will become the standard. Within the United States and globally, attention is being focused on obesity prevention efforts. A number of interest groups, coalitions, national governments, and intergovernmental organizations have examined the rising obesity and chronic disease problems in a variety of contexts, recognized its complicated nature, and proposed actions to reduce its prevalence both nationally and globally (e.g., WHO, 2000, 2003; DHHS, 2001; Health Council of the Netherlands, 2003; National Board of Health, 2003; New South Wales Department of Health, 2003; Canadian Institute for Health Information, 2004; Lobstein et al., 2004; Raine, 2004; United Kingdom Parliament, 2004; Willett and Domolky, 2004). Many of the strategies and action plans that have been developed from these efforts do not differ greatly from the recommendations in this report. The committee has gained insights from these efforts, and in this report draws together the evidence on obesity prevention, nutrition, and physical activity with the lessons learned from other public health issues (Box 4-2) to develop an action plan for childhood obesity prevention that is as informed, responsive, and realis-
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Preventing Childhood Obesity: Health in the Balance BOX 4-2 Lessons Learned from Other Public Health Issues and Potential Applicability to Obesity Prevention (see Appendix D) Advertising—Although obesity prevention does not involve restricted products to minors as is pertinent for tobacco and alcohol product advertising, there are similar concerns regarding young children’s inability to detect persuasive intent. Consumer information—Providing information to consumers has many parallels including the need for label information on tobacco, food, and drug products. Public education campaigns to convey public health messages such as those regarding youth smoking, and seat belt and child car seat use provide examples for obesity prevention media campaigns. Grassroots efforts and coalition building—Community organizations (including youth and civic organizations) are active in health promotion efforts and coalitions resulting from grassroots efforts have been successful in legislative and social changes (e.g., drunk driving laws). School environment—Changes to promoting a healthier overall school environment have parallels in smoking bans in schools. Further, classroom education and particularly health education efforts focus on a number of health promotion topics including safety, HIV prevention, and violence prevention. Health-care system—As with numerous other health promotion issues, the health-care system provides opportunities for parent and child education as well as for prevention interventions such as administering vaccines. Changes in the physical environment—Modifications of highways, roads, and intersections to enhance pedestrian and traveler safety provide parallel examples for the funding, regulatory, and prioritization efforts required to enhance opportunities for physical activity. Government support and funding—The long-term commitment from both federal and state governments for research, surveillance, and program efforts on a number of public health issues (e.g., highway improvements, research centers, surveys) provides parallels for sustained efforts on obesity prevention. Industry involvement—Numerous health-promoting products such as sunscreens are developed and marketed by industry. Comprehensive approach—As indicated in Box 4-1, comprehensive approaches have been used in enhancing highway safety and in preventing tobacco use by youth. A similar comprehensive effort is suggested for obesity prevention. Taxation and pricing—Obesity prevention efforts do not involve access to a restricted product for youth (as do tobacco and alcohol prevention efforts). Excise taxes and pricing strategies have played an important role in tobacco control efforts. However, it is more difficult to identify specific food and beverage products on which to impose taxes or tax breaks. Litigation changed the tobacco control environment including the public’s view of the issue. It is unclear whether the same issues that led to litigation for tobacco are relevant to obesity prevention. Access and opportunity—For restricted products, laws and regulations to restrict access to tobacco and alcohol have decreased availability. The ubiquitous nature of foods and beverages makes that a less feasible option for obesity prevention.
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Preventing Childhood Obesity: Health in the Balance tic as possible. The committee acknowledges, as have many other similar efforts, that obesity prevention is a complex issue, that a thorough understanding of the causes and determinants of the obesity epidemic is lacking, and that progress will require changes not only in individual and family behaviors but also in the marketplace and the social and built environments. No simple solutions are anticipated; therefore, multiple stakeholders need to make a long-term commitment to improve opportunities for healthful nutrition and physical activity. Although this chapter focuses on actions that need to be taken by the federal, state, and local governments, it is essential to mobilize and involve the numerous private organizations that fund obesity prevention programs and initiatives. It is in the best interest of the nation’s children for all relevant stakeholders to make obesity prevention efforts a priority. The committee recognizes the importance of combined social deliberation, problem analysis, and social mobilization around the issue of childhood obesity prevention at different levels and in various settings. This report and others that follow can set forth recommendations and broadly outline suggested actions; however, many of the next steps for progress on this issue will involve discussions and interactions of the implementers and innovators—the people, agencies, and organizations concerned about this issue and ready to work together to develop, implement, and evaluate approaches to prevent childhood obesity that fit the needs of their state, county, community, school, or neighborhood. LEADERSHIP, COORDINATION, AND PRIORITY SETTING A National Priority The federal government has a long-standing commitment to programs that address nutritional deficiencies (beginning in the 1930s) and encourage physical fitness, but only recently has obesity been targeted. Physical activity and overweight/obesity are now designated as priority areas and leading health indicators in the nation’s health objectives, Healthy People 2010, developed by the Department of Health and Human Services (DHHS) in collaboration with state and territorial health officials and numerous national membership organizations. The goal set by Healthy People 2010 is to reduce the proportion of children and adolescents who are obese to 5 percent by 2010 (DHHS, 2000). Obesity prevention is a cross-cutting issue that does not naturally fall under the purview of any one federal department. It encompasses health concerns central to the mission of DHHS; nutrition, nutrition education, and food-related issues for which the U.S. Department of Agriculture (USDA) has responsibilities; and school curriculum and school environ-
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Preventing Childhood Obesity: Health in the Balance ment concerns that the Department of Education addresses. In addition, the agendas of numerous other federal departments include transportation, housing, and many other issues that are key to increasing physical activity levels and improving dietary quality and patterns. Given the importance of obesity prevention for the health of American children, and given the overarching nature of this issue, prevention efforts need to be coordinated at the highest federal levels. The committee recommends that the President request that the Secretary of DHHS convene a high-level task force that includes the Secretaries or senior officials from DHHS, Agriculture, Education, Transportation, Housing and Urban Development, Interior, Defense, and other relevant federal agencies. The goal of the task force would be to ensure coordinated budgets, policies, research efforts, and program requirements and establish effective interdepartmental collaboration and priorities for action. It would be important for the task force to meet on a regular basis with local and state officials, representatives from nongovernmental organizations including foundations and advocacy groups, industry representatives, civic and youth-related organizations, and other relevant stakeholders. It is expected that high-level focused attention on this issue will result in fostering interdisciplinary and interdepartmental research collaborations that span agriculture, health, behavioral sciences, economics, urban planning, and other relevant disciplines. Given the public health nature of the childhood obesity epidemic, it is the committee’s judgment that the Secretary of Health and Human Services should chair this coordinating task force. To maintain the momentum over the long term, the committee urges that the coordinating task force consider periodic reassessments of its organization and its goals. In the initial work of the task force, participation of the Secretaries of the departments or senior officials will be needed to give high-level visibility, authority, and credence to the coordinating efforts. However, it is unrealistic to expect such high-level participation to continue indefinitely. After 2 to 3 years, an assessment may be needed to determine the best way to continue the collaboration and keep the research partnerships energized. In any case, sustained coordination will be primary to addressing this health issue, and it is up to the federal departments to ensure that it is a long-term priority. As part of its focus on obesity prevention in children and youth, the federal government should document its efforts and progress through an annual report to the nation. This report, which would include updates on the new and recently evaluated efforts in each of the cabinet departments as well as on cross-cutting efforts, could be coordinated through the Centers for Disease Control and Prevention (CDC). Content would include up-to-date epidemiologic data on childhood obesity trends, the amount and
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Preventing Childhood Obesity: Health in the Balance sources of government funds that are targeted to childhood obesity prevention, information on programs and research, and the results of program evaluations. It would also be informative to have an overview of federal, state, and local policy measures that have been taken to address the issue, as well as profiles of model programs that show promise. Meanwhile, it will be important to continue the current intra- and interdepartmental collaboration efforts, including the National Institutes of Health (NIH) Task Force on Obesity Prevention (which coordinates efforts between the NIH institutes on this issue), and the 2005 Dietary Guidelines Advisory Committee (which is conducting a review of the current scientific and medical knowledge on childhood obesity in order to provide a technical report of recommendations to the Secretaries of DHHS and USDA that will inform the 2005 edition of the Dietary Guidelines for Americans; see Chapter 3). This review will ensure consistency of dietary recommendations across DHHS and USDA agencies regarding national dietary recommendations for the American public. Just as it has done with automobile and highway safety initiatives (Box 4-1), efforts to curb youth smoking, and current efforts to defend against potential bioterrorist threats, the federal government should set forth obesity prevention as a national health priority—one that is acted upon through extensive and sustained funding and a long-term commitment of resources (IOM, 2003). Congressional support will be crucial in ensuring that fundingis made available for pilot programs and for research, public education, and program efforts. Furthermore, congressional leadership is needed on issues such as nutritional standards for foods and beverages sold in schools and in other areas that need legislative authorization. The federal government should take a leadership role in the prevention of obesity in children and youth by making this issue a top priority for the U.S. Departments of Health and Human Services, Agriculture, and Education. This priority should be reflected in the departments’ public statements, programs, research priorities, and budgets. These departments along with other relevant federal entities (e.g., the Departments of Transportation, Housing and Urban Development, Interior, and Defense) should together pursue an integrated approach that promotes healthful eating and regular physical activity to achieve energy balance. STATE AND LOCAL PRIORITIES State and local governments have important roles to play in obesity prevention because they can focus on the specific needs of their communities’ populations (see Chapter 6). Many of the issues involved in preventing childhood obesity require decisions by county, city, or town officials. Ac-
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Preventing Childhood Obesity: Health in the Balance tions on street and neighborhood design, planning for parks and community recreational facilities, and locations of new schools and retail food facilities are usually up to the local zoning boards, planning commissions, and similar entities. Efforts can be tailored to local residents and institutions, and can be more quickly adapted and revised to meet changing demands and integrate new approaches. State governments and agencies, including state departments of health, education, and transportation, are also key to ensuring that obesity prevention policies are developed and programs are implemented. Further, state governments are responsible for programs that provide food assistance, address the consequences of obesity (e.g., diabetes and heart disease), and influence health spending and policy (such as Medicaid, Title V [Maternal and Child Health], and direct funding for community development/housing and transportation). In some states, major policy decisions for school systems are made at the community or county level, but in others it is the state department of education that makes most of these decisions. As numerous and diverse programs and initiatives are being planned or under way in states and communities, organizations that bring together state and local leaders—such as the National Governors Association, the U.S. Conference of Mayors, the National Association of County and City Health Officials, the Association of State and Territorial Health Officials, and the American Public Health Association—can each raise awareness of obesity issues, facilitate the sharing of lessons learned, and help coordinate obesity prevention efforts. One avenue for expanding state-based obesity prevention efforts is through CDC’s grants program that focuses on local capacity building and implementation of programs to prevent obesity and other chronic diseases (CDC, 2004a). As discussed in Chapter 6, expansion of this grant program could be instrumental in establishing community demonstration projects. Twenty states received funding through these grants in fiscal year (FY) 2003. By expanding the total funding for the state grant programs, needed resources could be allocated to support additional states, particularly those with the highest prevalence of childhood and youth obesity. For example, the committee notes the critical role that the federal government has played in highway safety by providing states with grant funding (the Section 402 State and Community Highway Safety Grant program); these funds have been used for the development and evaluation of new innovative programs to increase the use of seat belts and child safety seats (IOM, 1999). Another recent initiative to provide funds for city- and community-based health efforts is the DHHS Steps to a Healthier U.S. Initiative (see Chapter 5). In 2003, DHHS provided 12 grants to promote community and tribal initiatives focused on reducing the burden of diabetes, overweight, obesity, and asthma and emphasizing efforts to address physical inactivity,
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Preventing Childhood Obesity: Health in the Balance poor nutrition, and tobacco use. Evaluation and further funding of this program is encouraged. State and local governments should make childhood obesity prevention a priority by devoting resources to this issue and providing leadership in launching and evaluating prevention efforts. State and Local Public Health Agencies Government public health agencies are critical components of the nation’s response to childhood obesity at national, state, and local levels, not only because the public health workforce has the needed expertise, but also because it has access to a large number of children, youth, and families; the ability to galvanize community efforts; and the resources to implement prevention programs. As the only institutions with the mission and legal mandate to protect the health of the public-at-large, federal, state, and local government public health agencies are the most publicly accountable entities within the health system. Public health has a long record of remarkable achievement despite modest resources, and the recent infusion of federal support to bolster preparedness for biological terrorism has strengthened the infrastructure to respond to disease emergencies (IOM, 2003). The state and local public health agencies in particular comprise the front line of the public health system. Although they are in an ideal position to assess the childhood obesity epidemic and the local conditions that are fueling it, these agencies need to be restructured for collaborative approaches that address behavioral, social, and environmental factors and that involve diverse community stakeholders and engage even the most disenfranchised communities. Such partners can include schools, child-care centers, nutrition services, parks and recreation departments, civic and ethnic organizations, faith-based groups, businesses, and community planning and transportation boards (see Chapter 6). As noted above, the committee urges increased funding for CDC’s program of state-based obesity prevention grants to provide the resources needed by state and local departments of health and others for improved surveillance efforts to identify specific community, state, and regional issues; training of public health professionals on obesity prevention; planning, implementing, and evaluating obesity prevention efforts including support for community coalitions and other collaborative efforts with community stakeholders, schools, and other key partners; and development of better tools for public communication. Health departments have the added dimension of serving as regulator or educator of standards for practice. Immunization programs, tobacco control efforts, and food service or restaurant inspection are all examples of public health (or environmental health) agencies overseeing and informing
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Preventing Childhood Obesity: Health in the Balance private-sector entities in order to protect health. With sufficient resources and staff training, public health and environmental health agencies may be able to develop complementary obesity-related programs to educate food service workers on nutritional values and portion size, for example, and to monitor and sanction institutional compliance with nutrition and physical activity standards for children. State and local public health agencies should make childhood obesity prevention a priority and work collaboratively with families, communities, schools, health- and medical-care providers, and industry to ensure that outcome. Further, state and local governments should increase funding for their health agencies so that they can more fully implement and evaluate obesity prevention efforts. State and local public health agencies should work with other state and local agencies, such as planning and public works departments, in establishing an interagency and multisectoral coordinating task force to facilitate collaborative planning, implementation, and assessment; coordinate and leverage governmental and nongovernmental resources; assure the capacity, workforce skills, standards, and resources necessary to achieve obesity prevention goals; support community coalitions (see Chapter 6); and work with community partners. RESEARCH AND EVALUATION Much remains to be learned about the causes and correlates of childhood obesity, as well as the optimum measures for preventing it. Experimental behavioral research and community-based research are key to learning more about changes in dietary and physical activity behaviors in individuals and populations (see Chapter 9). Moreover, as discussed elsewhere in this report, the funding and evaluation of a wide variety of obesity prevention intervention approaches are critical, given that there is a dearth of knowledge on this subject. Interventions focused on high-risk populations are particularly important. Such programs should be culturally relevant and designed to address the barriers to healthy lifestyles in these populations’ physical and social environments. An interdisciplinary research effort is greatly needed. Topics as diverse as the impacts of the built environment on health and behavior, gene-environment interactions, and the social underpinnings of healthful lifestyles require a research approach that embraces and encourages interdisciplinary research in agricultural and food sciences, nutritional sciences, economics, public health, marketing, behavioral and social sciences, policy sciences, urban planning, physiology, and health care. Innovative intervention designs, collaborative research efforts, and rigorous evaluation are key. A frequently overlooked component of the research cycle—the rapid translation and diffusion of effective programs and policies to community set-
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Preventing Childhood Obesity: Health in the Balance tings—is especially vital for making needed headway in obesity prevention efforts. Such transfer necessarily involves innovative intervention design and rigorous evaluation (see Chapter 3). Because nutrition, physical activity, and obesity research encompass broad areas of investigation, federally funded research efforts are now dispersed amongst a number of U.S. agencies, including NIH, CDC, and USDA. In FY 2003, NIH spent $379 million on obesity-related research (NIH, 2004b). The NIH Obesity Research Task Force recently developed a strategic plan, focused primarily on the biobehavioral causes of obesity, for coordinating the NIH efforts (NIH, 2004a). CDC funds a range of state-based nutrition and physical activity grants, in addition to its own extensive epidemiologic efforts, to study the correlates of the obesity epidemic. USDA conducts extensive nutrition research and funds six human nutrition research centers across the country, one of them specifically devoted to children’s nutrition (including childhood obesity). The interdisciplinary nature of obesity-related research, however, offers exciting opportunities for strengthening and expanding intra- and interdepartmental research efforts. USDA, for example, could link land grant institutions and other higher education entities with federal nutrition assistance programs and could field multidisciplinary teams to evaluate program changes (NRC, 2004). The federal investment in research on the prevention of childhood obesity must be strengthened. Further, foundations and other health-related organizations that fund research should consider designating childhood obesity prevention as a key area for funding. Interdisciplinary efforts should emphasize behavioral and community-based research, particularly in addressing childhood obesity prevention in high-risk populations. A top research priority is the evaluation of obesity prevention interventions (see Chapter 9). Despite broad acknowledgement of the importance of the obesity crisis and the urgent need for effective prevention approaches, systematic reviews of the literature find few high-quality studies of the efficacy and/or effectiveness of various interventions to prevent weight gain and obesity in children (Campbell et al., 2002). As discussed throughout the report, there are many studies on correlates of obesity, physical activity, sedentary behavior, and various dietary intake patterns, many of which conclude that their findings will be useful in designing effective prevention programs. However, much of this research does not bear directly on understanding how best to manipulate these correlates to achieve changes in children’s physical activity, sedentary behavior, diet, or weight. As a result, there are gaps in knowledge regarding how to successfully apply current understandings of causes and correlates into feasible and efficacious interventions and, subsequently, effective public health programs. Thus there is a need for more experimental research—studying purposeful manipulations
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Preventing Childhood Obesity: Health in the Balance ance and the benefits to children of healthful food choices and regular physical activity. Some of these programs were developed to accomplish goals other than obesity prevention, and evaluation of how to best use them to respond to the current information needs for obesity prevention may be needed. Children, youth, and their families need to have the information to make positive lifestyle decisions just as they need access to nutritious foods and recreational facilities in order to implement these choices (see Chapter 8). Providing obesity-related information to parents and families is often quite a challenge, because there is no one source or avenue throughout the United States for parent education. Several options are available at present, including federal and state nutrition education programs, parenting magazines and other media, health-care visits, and school-based programs. However, other innovative approaches need to be explored. Program implementation efforts should particularly address childhood obesity prevention in high-risk populations. Some of the ongoing federal food and nutrition efforts—including EFNEP, FSP, WIC, the National School Lunch Program (NSLP), the School Breakfast Program (SBP), the Summer Food Service Program, and the Child and Adult Care Food Program (CACFP)—address the needs of low-income, high-risk populations that have significant health disparities. But these programs could do more, even within their existing infrastructure, through a sustained commitment to funding for obesity prevention research and intervention development, implementation, and evaluation. Federal support is needed for programs that emphasize improved nutrition and physical activity in children, youth, and their families, with particular attention paid to populations at high risk of obesity. These programs should be required to have strong evaluation components, and the evaluation results should consequently be reflected in program refinements that strengthen their evidence-based approaches. Programs should also explore and evaluate new approaches to educating children and their families about concepts related to energy balance. NUTRITION ASSISTANCE PROGRAMS One in five Americans utilizes one or more of the 15 federal nutrition assistance programs (USDA, 2003a). Many of these programs provide food to children either directly, through the school breakfast and lunch programs, or indirectly, through vouchers that may be used by the family to supplement household food resources (Table 4-2). In FY 2001, approximately 4 million children were served each month by the FSP, 28 million were served daily by the NSLP, and 8.1 million were served daily by the SBP. Although the FSP includes a nutrition education component in selected states, the program is designed as a food equity
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Preventing Childhood Obesity: Health in the Balance TABLE 4-2 Selected Federal Food and Nutrition Assistance Programs FY 2002 Food Stamp Program Average monthly participation (millions) 19.1 Average benefit per person (dollars/month) 79.68 Total expenditures ($ billions) 20.7 WIC Average monthly participation (millions) 7.5 Total expenditures ($ billions) 4.3 National School Average daily participation (millions) 28.0 Lunch Program Total expenditures ($ billions) 6.9 School Breakfast Program Average daily participation (millions) 8.1 Total expenditures ($ billions) 1.6 Child and Adult Meals served in: Care Food Program Child care centers (millions) 984 Family child care homes (millions) 708 Adult day care centers (millions) 45 Total annual expenditures ($ billions) 1.9 SOURCE: USDA, 2003a. program to alleviate hunger and food insecurity; thus it does not have guidelines on the specific types of food that recipients may purchase with their benefits. There has been growing interest, however, in examining the relationships among food insecurity, federal nutrition assistance program participation, and the risk of obesity among children and youth. Because resource-constrained families are more likely to participate in nutrition programs, any association of program participation with obesity must be evaluated within the context of poverty and food insecurity (Frongillo, 2003). As noted in Chapter 3, food insecurity in children has not been associated with obesity, except in white girls aged 8 to 16 years (Alaimo et al., 2001; Casey et al., 2001; Frongillo, 2003). In fact, existing empirical data suggests that there is a lower risk of overweight and obesity in school-aged food-insecure girls who participated in the FSP, NSLP, and the SBP (Jones et al., 2003). The WIC program provides nutrition information, supplemental foods, and referrals to health care for low-income women, infants, and children up to age 5 who are at nutritional risk. Approximately half of all infants and 25 percent of all 1- to 4-year-old children in the United States participate in the WIC program (Oliveira et al., 2002). A study of low-income preschool
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Preventing Childhood Obesity: Health in the Balance children in 18 states and Washington, DC (most were WIC recipients) found that one in ten was overweight in 1995, a relative increase of 20 percent from 1983 (Mei et al., 1998). Two studies examining potential associations between the WIC food package and overweight status in children found that WIC foods did not contribute to overweight (CDC, 1996) and that the weight status of children in the WIC program was comparable to that of other low-income children (Burstein et al., 2000). The Institute of Medicine is currently conducting a study to review the nutritional needs of the populations served by the WIC Program, assess their supplemental nutritional needs, and propose recommendations for the contents of the WIC food packages. Given that a great deal is known about good nutrition and the dietary composition of balanced diets, it would be advantageous to the health of children participating in federal nutrition assistance programs if nutrient-rich foods were made available and if there was access to ethnically and culturally appropriate foods. The committee is particularly interested in urging USDA to expand pilot programs that focus on increasing the availability of fresh fruits and vegetables and other nutritious foods or provide incentives for the purchase of these items. Ideas for such programs have included double or specifically designated fruit and vegetable vouchers; coupons or other discount promotions; and the ability to use electronic benefit transfer cards at farmers’ markets or community-supported agricultural markets (GAO, 2002). Additionally, a systematic study should examine potential strategies for improving the community food environment to ensure that FSP recipients have access to supermarkets, farmers’ markets, and other venues that provide fresh, high-quality, and affordable produce and other healthful foods (see Chapter 6). In addition to their current objectives to improve food access and dietary quality, the federal nutrition assistance programs (e.g., WIC, FSP) should include obesity prevention as an explicit goal for the populations served. Congress should request independent assessments of these programs to ensure that each provides adequate access to healthful dietary choices (including fruits, vegetables, and whole grains) for the populations served. USDA should also continue to explore pilot programs within the nutrition assistance programs that encourage diet and physical activity behaviors that promote energy balance at a healthy weight in children and youth. AGRICULTURAL POLICIES As the traditional paradigm of “farm to table” shifts to one of “table to farm,” driven by consumer demand and an awareness of the connections between diet and health, decision makers in the United States should take a new look at the impact of agricultural and food policies (NRC, 2004). The
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Preventing Childhood Obesity: Health in the Balance committee acknowledges that the nation’s food supply is part of a global food system, and that many food-related issues lie outside of any one nation’s purview. However, the committee also realizes that the global implications of domestic solutions to the childhood obesity epidemic should be thoughtfully considered so that new problems are not created that may produce adverse consequences (Appendix D). There are a number of mechanisms by which U.S. federal agricultural policies may potentially affect the types of foods available to and marketed to children. For example, schools participating in the NSLP may choose to receive entitlement commodities purchased by USDA specifically for the program or receive bonus commodities from USDA to bolster the agricultural markets for particular products (to address temporary surpluses or to help stabilize farm prices) (USDA, 2002, 2004b). In the 2001-2002 school year, USDA’s Agricultural Marketing Service and Farm Service Agency together spent more than $765 million on school lunch entitlement purchases and approximately $58 million in providing bonus commodities (USDA, 2004b). These included beef, fish, poultry, eggs, fruits, vegetables, flours, grains, dairy products, and peanut products. As discussed in Chapter 7, there are several federal, state, and local programs at present, such as the Department of Defense’s Fresh Produce Program, that provide the distribution mechanisms for delivering fresh produce from farms to schools. A second set of policies to examine involves the check-off programs, used for agriculture products such as beef, pork, and dairy, in which producers are required to donate money—a fixed amount for each unit sold—to a fund established by federal legislation but run by a national private-sector board (Dairy Management, 2004; National Pork Board, 2004; USDA, 2004a). For example, the National Pork Board reports that pork producers and importers pay 40 cents on each $100 when pigs or pork products are sold; these funds generated $47.8 million in 2003 (National Pork Board, 2004) for use in advertising, marketing, education, research, and other programs that promoted the commodity. Concerns have been raised about the many factors that influence food demand and food consumption behaviors of Americans—the types and prices of available foods, technological advances, time pressures, and government policies on agriculture, taxes, and exports/imports—which are outside of consumer control (NRC, 2004). A review of agricultural policies could identify unintended effects of U.S. agricultural subsidies on human health. For example, Americans’ per capita consumption of caloric sweeteners—primarily sucrose derived from cane, beets, and corn (notably high fructose corn syrup)—increased by 43 pounds, or 39 percent, between 1950-1959 and 2000 (USDA, 2003b). In 2000, the average American consumed 152 pounds of caloric sweeteners, which was equivalent to 52 teaspoons of added sugars per person per day
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Preventing Childhood Obesity: Health in the Balance (USDA, 2003b), more than 40 percent of which came from high fructose corn syrup (Bray et al., 2004). The possible relationships among agricultural policies (such as corn subsidies and the production and use of high fructose corn syrup in the U.S. food supply), the obesity epidemic (Bray et al., 2004), and the marked increase in type 2 diabetes (Gross et al., 2004; Schulze et al., 2004) warrant further investigation. An independent assessment should be conducted of U.S. agricultural policies, including agricultural subsidies and commodity programs, that may affect the types and quantities of foods available to children through the federal food assistance programs. Further, other efforts (such as check-off programs) that have involved federal legislation should be examined to ensure that they work to promote a healthful dietary intake among children. Policies and programs should be revised as necessary to promote a U.S. food system that supports energy balance at a healthy weight. OTHER POLICY CONSIDERATIONS The imposition of taxes on certain foods or beverages, particularly high-calorie food items or those with low nutrient density, has been discussed with regard to the obesity epidemic. Several states including Arkansas, Tennessee, Virginia, and Washington, currently impose excise taxes on soft drinks. Although the tax rates have been found to be too small to affect sales, in certain jurisdictions the revenues generated are substantial but generally have not been used to fund obesity prevention activities (Jacobson and Brownell, 2000). It is not known whether imposing a sales tax on designated foods such as soft drinks would have a significant effect on beverage sales (Jacobson and Brownell, 2000). Moreover, there is the difficulty of determining which foods would be taxable—for example, how to define soft drink and snack foods (Jacobson and Brownell, 2000). Taxation and pricing strategies have been found to contribute to tobacco prevention and control efforts (Levy et al., 2004). Pricing policies for food are much more complex than tobacco and there is limited evidence about the price elasticity of high-energy-dense foods (Yach et al., 2003). It is notable that other countries, such as Norway, have effectively used agricultural policies such as consumer and producer subsidies to encourage the consumption of healthful foods (Milio, 1998). The committee has carefully considered the issues regarding taxes on specific foods, particularly soft drinks and energy-dense snack foods, but at this time, it is the committee’s judgment that there is not sufficient evidence to make a strong recommendation either for or against taxing these foods. More research is needed to determine objective methods for defining and characterizing foods based on nutritional considerations such as the quality and quantity of nutrients or the energy density. Additionally, because low-
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Preventing Childhood Obesity: Health in the Balance income families spend a greater proportion of their household income on food than do higher-income families (Nord et al., 2003), taxes on foods may have the effect of being regressive and may lead to unintended consequences such as increasing food insecurity. In any case, taxation may not address the main issue, that many people will not consume greater amounts of healthful foods, even if their relative prices are lower, simply because they prefer energy-dense foods. Because some states are already taxing specific types of food or beverage products, studying these examples may prove useful. The committee suggests that research into the effects of taxation and pricing strategies be considered a priority to help shed light on the potential outcomes of more broadly applying taxation as a public health strategy for promoting improved dietary behaviors, more physical activity, and reduced sedentary behaviors. RECOMMENDATION Childhood obesity is a serious nationwide health problem requiring urgent attention and a population-based prevention approach. Innovative ideas, commitments of time and resources by diverse sectors and stakeholders, and sustained efforts involving individual, institutional, and societal changes are needed to ensure that all children grow up physically and emotionally healthy. Also needed is national leadership that elevates childhood obesity prevention to a top national health priority and dedicates the funding and resources required to make this goal a long-term commitment. Only through policies, legislation, programs, and research will meaningful changes be made. Steady monitoring and evaluation of those changes will inform and refine future efforts. Prevention of obesity in children and youth should be a national public health priority. Recommendation 1: National Priority Government at all levels should provide coordinated leadership for the prevention of obesity in children and youth. The President should request that the Secretary of the DHHS convene a high-level task force to ensure coordinated budgets, policies, and program requirements and to establish effective interdepartmental collaboration and priorities for action. An increased level and sustained commitment of federal and state funds and resources are needed. To implement this recommendation, the federal government should:
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Preventing Childhood Obesity: Health in the Balance Strengthen research and program efforts addressing obesity prevention, with a focus on experimental behavioral research and community-based intervention research and on the rigorous evaluation of the effectiveness, cost-effectiveness, sustainability, and scaling up of effective prevention interventions Support extensive program and research efforts to prevent childhood obesity in high-risk populations with health disparities, with a focus both on behavioral and environmental approaches Support nutrition and physical activity grant programs, particularly in states with the highest prevalence of childhood obesity Strengthen support for relevant surveillance and monitoring efforts, particularly NHANES Undertake an independent assessment of federal nutrition assistance programs and agricultural policies to ensure that they promote healthful dietary intake and physical activity levels for all children and youth Develop and evaluate pilot projects within the nutrition assistance programs that would promote healthful dietary intake and physical activity and scale up those found to be successful To implement this recommendation, state and local governments should: Provide coordinated leadership and support for childhood obesity prevention efforts, particularly those focused on high-risk populations, by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating in communities, neighborhoods, and schools Support public health agencies and community coalitions in their collaborative efforts to promote and evaluate obesity prevention interventions REFERENCES Alaimo K, Olson CM, Frongillo EA Jr. 2001. Low family income and food insufficiency in relation to overweight in US children: Is there a paradox? Arch Pediatric Adolesc Med 155(10):1161-1167. America on the Move. 2004. America on the Move. [Online]. Available: http:// www.americaonthemove.org [accessed May 15, 2004]. Bray GA, Nielsen SJ, Popkin BM. 2004. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr 79(4):537-543. Burstein NR, Fox MK, Hiller JB, Kornfeld R, Lam K, Price C, Rodda DT. 2000. Profile of WIC Children. Cambridge, MA. Prepared by Abt Associates for USDA, FNS, Office of Analysis, Nutrition, and Evaluation.
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Representative terms from entire chapter: