1
Introduction

AN EPIDEMIC OF CHILDHOOD OBESITY

Children’s health in the United States has improved dramatically over the past century. Vaccines targeting previously common childhood infections—such as measles, polio, diphtheria, tetanus, rubella, and Haemophilus influenza—have nearly eliminated these scourges. Through the widespread availability of potable water, improved sanitation, and antibiotics, diarrheal diseases and infectious diseases such as tuberculosis and pneumonia have diminished in frequency and as primary causes of infant and child deaths in the United States (CDC, 1999). Pervasive food scarcity and essential vitamin and mineral deficiencies have largely disappeared in the U.S. population (IOM, 1991; Kessler, 1995). The net result is that infant mortality has been lowered by over 90 percent, contributing to the substantial increase in life expectancy—more than 30 years—since 1900 (CDC, 1999). Innovations such as seatbelts, child car seats, and bike helmets, meanwhile, have contributed to improved children’s safety, and fluoridation of municipal drinking water has enhanced child and adolescent dentition (CDC, 1999).

Given this steady trajectory toward a healthier childhood and healthier children, we begin the 21st century with a startling setback—an epidemic1

1

The term “epidemic” is used in reference to childhood obesity as there have been an unexpected and excess number of cases on a steady increase in recent decades.



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Preventing Childhood Obesity: Health in the Balance 1 Introduction AN EPIDEMIC OF CHILDHOOD OBESITY Children’s health in the United States has improved dramatically over the past century. Vaccines targeting previously common childhood infections—such as measles, polio, diphtheria, tetanus, rubella, and Haemophilus influenza—have nearly eliminated these scourges. Through the widespread availability of potable water, improved sanitation, and antibiotics, diarrheal diseases and infectious diseases such as tuberculosis and pneumonia have diminished in frequency and as primary causes of infant and child deaths in the United States (CDC, 1999). Pervasive food scarcity and essential vitamin and mineral deficiencies have largely disappeared in the U.S. population (IOM, 1991; Kessler, 1995). The net result is that infant mortality has been lowered by over 90 percent, contributing to the substantial increase in life expectancy—more than 30 years—since 1900 (CDC, 1999). Innovations such as seatbelts, child car seats, and bike helmets, meanwhile, have contributed to improved children’s safety, and fluoridation of municipal drinking water has enhanced child and adolescent dentition (CDC, 1999). Given this steady trajectory toward a healthier childhood and healthier children, we begin the 21st century with a startling setback—an epidemic1 1 The term “epidemic” is used in reference to childhood obesity as there have been an unexpected and excess number of cases on a steady increase in recent decades.

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Preventing Childhood Obesity: Health in the Balance of childhood obesity. This epidemic is occurring in boys and girls in all 50 states, in younger children as well as in adolescents, across all socioeconomic strata, and among all ethnic groups—though specific subgroups, including African Americans, Hispanics, and American Indians, are disproportionately affected (Ogden et al., 2002; Caballero et al., 2003). At a time when we have learned that excess weight has significant and troublesome health consequences, we nevertheless see our population, in general, and our children, in particular, gaining weight to a dangerous degree and at an alarming rate. The increasing prevalence of childhood obesity throughout the United States has led policy makers to rank it as a critical public health threat for the 21st century (Koplan and Dietz, 1999; Mokdad et al., 1999, 2000; DHHS, 2001). Over the past three decades since the 1970s, the prevalence of childhood obesity (defined in this report as a gender- and age-specific body mass index [BMI] at or above the 95th percentile on the 2000 CDC BMI charts) has more than doubled for preschool children aged 2 to 5 years and adolescents aged 12 to 19 years, and it has more than tripled for children aged 6 to 11 years (see Chapter 2; Ogden et al., 2002). Approximately nine million American children over 6 years of age are already considered obese. These trends mirror a similar profound increase in U.S. adult obesity and co-morbidities over a comparable time frame, as well as a concurrent rise in the prevalence of childhood and adult obesity and related chronic diseases internationally, in developed and developing countries alike (WHO, 2002, 2003; Lobstein et al., 2004). IMPLICATIONS FOR CHILDREN AND SOCIETY AT LARGE Many of us consider our weight and height as personal statistics, primarily our own, and occasionally our physician’s concern. Our weight is something we approximate on forms and applications requiring this information. Body size has been a cosmetic issue rather than a health issue throughout most of human history, but scientific study has changed this view. One’s aesthetic preference for a lean versus a plump body type may be related to personal taste, cultural and social norms, and association of body type with wealth or well-being. However, the implications of a wholesale increase in BMIs are increasingly becoming a public health problem. Thus, we need to acknowledge the sensitive personal dimension of height and weight, while also viewing weight as a public health issue, especially as the weight levels of children, as a population, are proceeding on a harmful upward trajectory. The as yet unabated epidemic of childhood obesity has significant ramifications for children’s physical health, both in the immediate and long term, given that obesity is linked to several chronic disease risks. In a

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Preventing Childhood Obesity: Health in the Balance population-based sample, approximately 60 percent of obese children aged 5 to 10 years had at least one physiological cardiovascular disease (CVD) risk factor—such as elevated total cholesterol, triglycerides, insulin, or blood pressure—and 25 percent had two or more CVD risk factors (Freedman et al., 1999). The increasing incidence of type 2 diabetes in young children (previously known as adult onset diabetes) is particularly startling. For individuals born in the United States in 2000, the lifetime risk of being diagnosed with diabetes at some point in their lives is estimated at 30 percent for boys and 40 percent for girls if obesity rates level off (Narayan et al., 2003).2 The estimated lifetime risk for developing diabetes is even higher among ethnic minority groups at birth and at all ages (Narayan et al., 2003). Type 2 diabetes is rapidly becoming a disease of children and adolescents. In case reports limited to the 1990s, type 2 diabetes accounted for 8 to 45 percent of all new childhood cases of diabetes—in contrast with fewer than 4 percent before the 1990s (Fagot-Campagna et al., 2000). Young people are also at risk of developing serious psychosocial burdens related to being obese in a society that stigmatizes this condition, often fostering shame, self-blame, and low self-esteem that may impair academic and social functioning and carry into adulthood (Schwartz and Puhl, 2003). The growing obesity epidemic in children, and in adults, affects not only the individual’s physical and mental health but carries substantial direct and indirect costs for the nation’s economy as discrimination, economic disenfranchisement, lost productivity, disability, morbidity, and premature death take their tolls (Seidell, 1998). States and communities are obliged to divert resources to prevention and treatment, and the national health-care system is burdened with the co-morbidities of obesity such as type 2 diabetes, hypertension, CVD, osteoarthritis, and cancer (Ebbeling et al., 2002). The obesity epidemic may reduce overall adult life expectancy (Fontaine et al., 2003) because it increases lifetime risk for type 2 diabetes and other serious chronic disease conditions (Narayan et al., 2003), thereby potentially reversing the positive trend achieved with the reduction of infectious diseases over the past century. The great advances of genetics and other biomedical discoveries could be more than offset by the burden of illness, disability, and death caused by too many people eating too much and moving too little over their lifetimes. 2 These projections are based on data on the lifetime risk of diagnosed diabetes and do not account for undiagnosed cases. The data do not allow for differentiation between type 1 and type 2 diabetes. However, the major form of diabetes in the U.S. population is type 2, which accounts for an estimated 95 percent of diabetes cases (Narayan et al., 2003).

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Preventing Childhood Obesity: Health in the Balance Aside from the statistics, we can see the evidence of childhood obesity in our community schoolyards, in shopping malls, and in doctors’ offices. There are confirmatory journalistic reports of the epidemiologic trends in weight—from resizing of clothing to larger coffins to more spacious easy chairs to the increased need for seatbelt extenders. These would be of passing interest and minimal importance were it not for the considerable health implications of this weight gain for both adults and children. For example, compared with adults of normal weight, adults with a BMI of 40 or more have a seven-fold increased risk for diagnosed diabetes (Mokdad et al., 2003). Indeed, the obesity epidemic places at risk the long-term welfare and readiness of the U.S. military services by reducing the pool of individuals eligible for recruitment and decreasing the retention of new recruits. Nearly 80 percent of recruits who exceed the military accession weight-for-height standards at entry leave the military before they complete their first term of enlistment (IOM, 2003). What might our population look like in the year 2025 if we continue on this course? In a land of excess calories ingested and insufficient energy expended, the inevitable scenario is a continued increase in average body size and an altered concept of what is “normal.” Americans with a BMI below 30 will be considered small and obesity will no longer be newsworthy but accepted as the social norm. While the existence and importance of the increase in the population-wide obesity problem are no longer debated, we are still mustering the determination to forge effective solutions. We must remind ourselves that social changes to transform public perceptions and behaviors regarding seatbelt use, smoking cessation, breastfeeding, and recycling would have sounded unreasonable just a few decades ago (Economos et al., 2001), yet we have acted vigorously and with impressive results. How to proceed similarly in meeting the formidable childhood obesity challenge is the focus of this Institute of Medicine (IOM) report. The 19-member IOM committee was charged with developing a prevention-focused action plan to decrease the prevalence of obesity in children and youth in the United States. The primary emphasis of the committee’s task was on examining the behavioral and cultural factors, social constructs, and other broad environmental factors involved in childhood obesity and identifying promising approaches for prevention efforts. This report presents the committee’s recommendations for many different segments of society from federal, state, and local governments (Chapter 4), to industry and media (Chapter 5), local communities (Chapter 6), schools (Chapter 7), and parents and families (Chapter 8).

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Preventing Childhood Obesity: Health in the Balance CONTEXTS FOR ACTION Investigating the causes of childhood obesity, determining what to do about them, and taking appropriate action must address the variables that influence both eating and physical activity. Seemingly straightforward, these variables result from complex interactions across a number of relevant social, economic, cultural, environmental, and policy contexts. U.S. children live in a society that has changed dramatically in the three decades over which the obesity epidemic has developed. Many of these changes, such as both parents working outside the home, often affect decisions about what children eat, where they eat, how much they eat, and the amount of energy they expend in school and leisure time activities (Ebbeling et al., 2002; Hill et al., 2003). Other changes, such as the increasing diversity of the population, influence cultural views and marketing patterns. Lifestyle modifications, in part the result of media usage and content together with changes in the physical design of communities, affect adults’ and children’s levels of physical activity. Many of the social and cultural characteristics that the U.S. population has accepted as a normal way of life may collectively contribute to the growing levels of childhood obesity. The broad societal trends that impact weight outcomes are complex and clearly multifactorial. With such societal changes, it is difficult to tease out the quantitative and qualitative role of individual contributing factors. While distinct causal relationships may be difficult to prove, the dramatic rise in childhood obesity prevalence must be viewed within the context of these broad societal changes. An understanding of these contexts, particularly regarding their potential to be modified and how they may facilitate or impede development of a comprehensive obesity prevention strategy, is therefore essential. This next section provides a useful background to understand the multidimensional nature of the childhood obesity epidemic. Lifestyle and Demographic Trends The interrelated areas of family life, ethnic diversity, eating patterns, physical activity, and media use—discussed below—are all aspects of societal change that must be considered. Singly and in concert, the trends in these areas will strongly influence prospects for preventive and corrective measures. Family Life The changing context of American families includes several distinct trends such as the shifting role of women in society, delayed marriage,

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Preventing Childhood Obesity: Health in the Balance childbearing outside of marriage, higher divorce rates, single parenthood, and work patterns of parents (NRC, 2003). Among the many important transformations that have occurred are expanded job opportunities for women, which have led to more women entering the workforce. Economic necessities have also prompted this trend. Moreover, married mothers are increasingly more likely than they were in the past to remain in the labor force throughout their childbearing years. Women’s participation in the labor force increased from 36 percent in 1960 to 58 percent in 2000 (Luckett Clark and Weismantle, 2003). Since 1975, the labor force participation rate of mothers with children under age 18 has grown from 47 to 72 percent, with the largest increase among mothers with children under 3 years of age (U.S. Department of Labor, 2004). Over the same period, men’s labor force participation rates declined slightly from 78 percent to 74 percent (Population Reference Bureau, 2004b). In 2002, only 7 percent of all U.S. households consisted of married couples with children in which only the husband worked. These trends, together with lower fertility rates, a decrease in average household size, and the shift in household demographics from primarily married couples with children to single person households and households without children, have caused the number of meal preparers in U.S. households who cook for three or more people to decline (Population Reference Bureau, 2003; Sloan, 2003). It has been suggested that smaller households experience fewer economies of scale in home preparation of meals than do larger families. Preparing food at home involves a set amount of time for every meal that changes minimally with the number of persons served. Eating meals out involves the same marginal costs per person. Moreover, changes in salary and the lower prices of prepared foods may have reduced the value of time previously used to prepare at-home meals. Thus, incentives have been shifted away from home production toward eating more meals away from home (Sturm, 2004). Time-use trends for meal preparation at home reveal a gradual decline from 1965 to 1985 (44 minutes per day versus 39 minutes per day) and a steeper decline from 1985 to 1999 (39 minutes per day versus 32 minutes per day) (Robinson and Godbey, 1999; Sturm, 2004). Ethnic Diversity The racial and ethnic composition of children in the United States is becoming more diverse. In 2000, 64 percent of U.S. children were white non-Hispanic, 15 percent were black non-Hispanic, 4 percent were Asian/ Pacific Islander, and 1 percent were American Indian/Alaska Native. The proportion of children of Hispanic origin has increased more rapidly than the other racial and ethnic groups from 9 percent of the child population in

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Preventing Childhood Obesity: Health in the Balance 1980 to 16 percent in 2000 (Federal Interagency Forum on Child and Family Statistics, 2003). Differences among ethnic groups (e.g., African American, American Indian, Hispanic, and Asian/Pacific Islanders) include variations in household composition and size—particularly larger household size in Hispanic and Asian populations (Frey, 2003)—and in other aspects of family life such as media use and exposure, consumer behavior, eating, and physical activity patterns (Tharp, 2001; Nesbitt et al., 2004). Ethnic minorities are projected to comprise 40.2 percent of the U.S. population by 2020 (U.S. Census Bureau, 2001), and the food preferences of ethnic families are expected to have a significant impact on consumers’ food preferences and eating patterns (Sloan, 2003). The higher-than-average prevalence of obesity in several ethnic minority populations may indicate differences in susceptibility to unfavorable lifestyle trends and the consequent need for specially designed preventive and corrective strategies (Kumanyika, 2002; Nesbitt et al., 2004). Eating Patterns As economic demands and the rapid pace of daily life increasingly constrain people’s time, food trends have been marked by convenience, shelf stability, portability, and greater accessibility of foods throughout the entire day (Food Marketing Institute, 1996, 2003; French et al., 2001; Sloan, 2003). Food has become more available wherever people spend time. Because of technological advances, it is often possible to acquire a variety of highly palatable foods, in larger portion sizes, and at relatively low cost. Research has revealed a progressive increase, from 1977 to 1998, in the portion sizes of many types of foods and beverages available to Americans (Nielsen and Popkin, 2003; Smiciklas-Wright et al., 2003); and the concurrent rise in obesity prevalence has been noted (Nestle, 2003; Rolls, 2003). Foods eaten outside the home are becoming more important in determining the nutritional quality of Americans’ diets, especially for children (Lin et al., 1999b; French et al., 2001). Consumption of away-from-home foods comprised 20 percent of children’s total calorie intake in 1977-1978 and rose to 32 percent in 1994-1996 (Lin et al., 1999b). In 1970, household income spent on away-from-home foods accounted for 25 percent of total food spending; by 1999, it had reached nearly one-half (47 percent) of total food expenditures (Clauson, 1999; Kennedy et al., 1999). The trend toward eating more meals in restaurants and fast food establishments may be influenced not only by simple convenience but also in response to needs such as stress management, relief of fatigue, lack of time, and entertainment. According to a 1998 survey conducted by the National Restaurant Association, two-thirds of Americans indicated that patronizing

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Preventing Childhood Obesity: Health in the Balance a restaurant with family or friends allowed them to socialize and was a better use of their leisure time than cooking at home and cleaning up afterward (Panitz, 1999). For food consumed at home, never has so much been so readily available to so many—that is, to virtually everyone in the household—at low cost and in ready-to-eat or ready-to-heat form (French et al., 2001; Sloan, 2003). Increased time demands on parents, especially working mothers, have shifted priorities from parental meal preparation toward greater convenience (French et al., 2001), and the effects of time pressures are seen in working mothers’ reduced participation in meal planning, shopping, and food preparation (Crepinsek and Burstein, 2004). Industry has endeavored to meet this demand through such innovations as improved packaging and longer shelf stability, along with complementary technologies, such as microwaves, that have shortened meal preparation times. Another aspect of this trend toward convenience is an increased prevalence, across all age groups of children and youth, of frequent snacking and of deriving a large proportion of one’s total daily calories from energy-dense snacks (Jahns et al., 2001). At the same time, there has been a documented decline in breakfast consumption among both boys and girls, generally among adolescents (Siega-Riz et al., 1998) and in urban elementary school-age children as compared to their rural and suburban counterparts (Gross et al., 2004); further, children of working mothers are more likely to skip meals (Crepinsek and Burstein, 2004). There are also indications that children and adolescents are not meeting the minimum recommended servings of five fruits and vegetables daily recommended by the Food Guide Pyramid (Cavadini et al., 2000; American Dietetic Association, 2004). This trend is partially explained by the limited variety of fruits and vegetables consumed by Americans. In 2000, five vegetables—iceberg lettuce, frozen potatoes, fresh potatoes, potato chips, and canned tomatoes—accounted for 48 percent of total vegetable servings and six fruits (out of more than 60 fruit products)—orange juice, bananas, apple juice, apples, fresh grapes, and watermelon—accounted for 50 percent of all fruit servings (Putnam et al., 2002). These trends have contributed to an increased availability and consumption of energy-dense foods and beverages. As summarized in Table 1-1 and Figures 1-1 through 1-3, trends in the dietary intake of the general U.S. population parallel trends in the dietary intake of children and youth. A more in-depth discussion of caloric intake, energy balance, energy density, Dietary Guidelines for Americans, and the Food Guide Pyramid is included in Chapters 3, 5, and 7.

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Preventing Childhood Obesity: Health in the Balance Physical Activity Physical activity is often classified into different types including recreational or leisure time, utilitarian, household, and occupational. The direct surveillance of physical activity trends in U.S. adults began only in the 1980s and was limited to characterizing leisure-time physical activity. In 2001, CDC began collecting data on the overall frequency and duration of time spent in household, transportation, and leisure-time activity of both moderate and vigorous intensity in a usual week through the state-based Behavioral Risk Factor Surveillance System (BRFSS) (CDC, 2003c). National surveys conducted over the past several decades suggest an increase in population-wide physical activity levels among American men, women, and older adolescents; however, a large proportion of these populations still do not meet the federal guidelines for recommended levels of total daily physical activity.3 The data for children’s and youth’s leisure time and physical activity levels reveal a different picture than the adult physical activity trend data that are summarized in Table 1-2. Trend data collected by the Americans’ Use of Time Study, through time-use diaries, indicated that adults’ free time increased by 14 percent between 1965 and 1985 from 35 hours to an average total of nearly 40 hours per week (Robinson and Godbey, 1999). Data from other population-based surveys, including the National Health Interview Survey, National Health and Nutrition Examination Survey (NHANES), BRFSS, and the Family Interaction, Social Capital and Trends in Time Use Data (1998-1999), together with trend data on sports and recreational participation, suggest minor to significant increases in reported leisure-time physical activity among adults (Pratt et al., 1999; French et al., 2001; Sturm, 2004). Data from the 1990-1998 BRFSS4 revealed only a slight increase in self-reported physical activity levels among adults (from 24.3 percent in 1990 to 25.4 percent in 1998), and a decrease in respondents reporting no physical activity at all (from 30.7 percent in 1990 to 28.7 percent in 1998) (CDC, 2001). Women, older adults, and ethnic minority populations have been identified as having the greatest prevalence of leisure-time physical inactivity (CDC, 2004b). In general, the prevalence of self-reported, no leisure-time physical activity was highest in 1989, and declined to its lowest level in 15 years among all groups in 35 states and the District of Columbia based on 3 The Surgeon General’s report on physical activity and health suggests that significant health benefits can be obtained by Americans who include a moderate amount of physical activity (e.g., 30 minutes of brisk walking) on most if not all days of the week (DHHS, 1996). 4 The BRFSS is a population-based, randomly selected, self-reported telephone survey conducted among the noninstitutionalized U.S. adult population aged 18 years and older throughout the 50 states (CDC, 2003c).

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Preventing Childhood Obesity: Health in the Balance TABLE 1-1 Trends in Food Availability and Dietary Intake of the U.S. Population and of U.S. Children and Youtha Dietary Intake Trend U.S.Population U.S.Children and Youth Portion sizes of foods Portion sizes of most foods consumed by adults both at home and away from home (except pizza) increased between 1977 and 1996 (Nielsen and Popkin, 2003). Portion sizes for children aged 2 years and older increased for most foods consumed both at home and away from home between 1977 and 1996 (Nielsen and Popkin, 2003). Total energy intake derived from away-from-home sources Total energy intake increased from 18% to 34% for adults between 1977-1978 and 1995 (Lin et al., 1999a). Total energy intake increased from 20% to 32% for children between 1977-1978 and 1994-1996 (Lin et al., 1999b). Total energy intake Between 1971 and 2000, average energy intake increased from 2,450 to 2,618 calories for men and 1,542 to 1,877 kcal forwomen (CDC, 2004a). Between 1989 and 1991 and 1994-1996, total energy increased 8.6% and 9.5%, according to food supply and CSFII data, respectively (Chanmugan et al., 2003). Between 1983 and 2000, calories per capita increased by 20% (USDA, 2003) (Figure 1-1). No significant increased trends inenergy intake were observed in children aged 6-11 years between 1977-1978 and 1994-1996, 1998 (Enns et al., 2002). Total calories consumed by adolescent boys aged 12 to 19 years increased by 243 between 1977-1978 and 1994-1996 from 2,523 to 2,766 calories (Enns et al., 2003). Total calories consumed by adolescent girls aged 12 to 19 years increased by 123 between 1977-1978 and 1994-1996 from 1,787 to 1,910 calories (Enns et al., 2003). Total fat consumption Between 1971 and 2000, the percentage of calories from total fat decreased for men (from 36.9%to 32.8%) and women (from 36.1% to 32.8%) (CDC, 2004a). However, the intake of grams of total fat increased among women and decreased among men (CDC, 2004a) (Figure 1-2). Between 1965 and 1996, the proportion of energy from total fat consumed by children decreased from 39% to 32%, and saturated fat from 15% to 12% (Cavadini et al., 2000). Children aged 6 to 11 years in 1994-1996, 1998 consumed 25% of calories from discretionary fat (USDA, 2000; Enns et al., 2002).

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Preventing Childhood Obesity: Health in the Balance     For adolescents aged 12 to 19 years, girls consumed 25% and boys consumed 26% of their calories from added fat (USDA, 2000; Enns et al., 2003). Added dietary sweeteners Between 1977 and 2000, an 83 calorie/day increase in caloric sweeteners was observed in the U.S. for all individuals 2 years and older, representing a 22% increase in the proportion of energy derived from caloric sweeteners (Popkin and Nielsen,2003). Between 1982 and 1997, per capita consumption of sweetners increased 28% (34 pounds) (Putnam and Gerrior, 1999). Children aged 6 to 11 years in 1994 to 1996 and 1998 consumed 21-23 teaspoons of added sugars in a 1,800-2,000 calorie diet which exceeded the Food Guide Pyramid recommendation of 6-12 teaspoons for a 1,600-2,200 calorie diet (USDA, 1996; Enns et al., 2002). Dairy and milk consumption Between 1970 and 1997, the consumption of milk per capita decreased from 31 gallons to 24 gallons, while cheese consumption increased 146% from 11 pounds/person in 1970 to 28 pounds/person in 1997 (French et al., 2001). Americans consumed 2.5 times as much cheese and drank 23% less milk per capita in 1997 than in 1970 (Putnam and Gerrior, 1999). Milk consumption decreased by 37% in adolescent boys and 30% in adolescent girls between 1977-1978 and 1994 (Cavadini et al., 2000). In 1977-1978, children aged 6 to 11 years consumed four times as much milk as any other beverage, and adolescents aged 12 to 19 years drank 1.5 times as much milk as any other beverage. In 1994-1996 and 1998, children aged 6 to 11 consumed 1.5 times as much milk as soft drinks, and by 1994-1996 adolescents consumed twice as much soft drinks as milk (French et al., 2001).

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Preventing Childhood Obesity: Health in the Balance think of their child as healthy if he or she has no serious medical conditions, and they embrace the hope that the overweight child will outgrow the problem. They may also hesitate to raise weight-related issues due to their concerns that this may lower the child’s self-esteem and potentially encourage him or her to develop an eating disorder. School-age children, however, do not generally view obesity as a health problem as long as it does not significantly affect appearance and performance (Borra et al., 2003). Being obese, whether as a child or an adult, is highly stigmatized and viewed as a moral failing, among some educators (Price et al., 1987), health professionals (Teachman and Brownell, 2001), and even very young children (Cramer and Steinwert, 1998; Latner and Stunkard, 2003). Further, individuals and consumers vary in the priority they place on healthy eating and an active lifestyle, and they hold a spectrum of views on health regarding weight management, weight control, and wellness (Buchanan, 2000; Strategy One, 2003). Consumer research reveals that Americans express not having enough time to fit everything into their day that they would like to, with the consequence that their health may be neglected (Strategy One, 2003). In a recent national poll of 1,000 U.S. adult respondents, half of the respondents viewed obesity as a public health problem that society needs to solve while the other half considered it a personal responsibility or choice that should be dealt with privately (Lake Snell Perry & Associates, 2003). However, Americans do appear more uniformly willing to support proactive actions to reduce obesity in children and youth, especially in the school setting (Lake Snell Perry & Associates, 2003; Robert Wood Johnson Foundation, 2003; Widmeyer Polling & Research, 2003). Childhood obesity presumably engenders more support for societal-level approaches because children, who are thought to have less latitude in food and activity choices than adults, are unlikely to be blamed by society for becoming obese. Understanding consumer perceptions and knowledge of public awareness about obesity will be essential in order to design an effective multimedia and public relations campaign supporting obesity prevention (see Chapter 5). Emerging Programs and Policies As it has done with many other child health concerns, from whooping cough, polio, and measles to use of toddlers’ seats in automobiles, the United States is now addressing the growing problem of childhood obesity. State legislatures, federal agencies, school boards, teachers, youth programs, parents, and others are mobilizing to address the array of interrelated issues associated with the development, and potential prevention, of childhood obesity. Because adult overweight and obesity rates are even higher than

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Preventing Childhood Obesity: Health in the Balance those of children, many efforts focus on improving eating habits and encouraging physical activity for people of all ages. The range of these efforts is quite broad, and many innovative approaches are under way. As discussed throughout the report, many of these efforts are occurring at the grassroots level—neighborhood-specific or community-wide programs and activities encouraging healthy eating and promoting regular physical activity. A number of U.S. school districts, for instance, have established new standards for the types of food and beverages that will be available in their school systems (Prevention Institute, 2003). Many communities are examining the local availability of opportunities for physical activity and are working to expand bike paths and improve the walkability of neighborhoods. Further, community child- and youth-centered organizations (such as the Girl Scouts and the Boys and Girls Clubs of America) are adding or expanding programs focused on increasing physical activity. A national cross-sector initiative, Shaping America’s Youth, supported by the private sector (industry), nonprofit organizations, and the Department of Health and Human Services, is working to compile a registry of the relevant ongoing research and intervention programs across the country as well as funding sources. Evaluating these efforts and disseminating those that are most effective will be the challenge and goal for future endeavors. In many other countries where childhood obesity is a growing problem, including the United Kingdom, Sweden, Germany, France, Canada, and Australia, a broad array of national and community-level efforts and policy options are being pursued. Among these are the banning of vending machines in schools, developing restrictions for television advertising to children, and using taxes derived from energy-dense foods to support physical activity programs. PUBLIC HEALTH PRECEDENTS Public health problems of comparably broad scope and complexity have been successfully addressed in the past (Economos et al., 2001), and this experience gives us not only the confidence that childhood obesity too can be moderated, even prevented, but supplies us with some of the needed tools. This solid public health history of achievements is exemplified in Box 1-1 (CDC, 1999; Appendix D). Many of these problems were not apparent at first, and grew to become an accepted part of life before they were recognized and subsequently addressed. For example, in 1900, with only approximately 8,000 cars on the roads, it was surely inconceivable that motor vehicle deaths could reach a peak of 56,278 per year in 1972 (U.S. Department of Transportation, 1995; Waller, 2002). Multifocal interventions on vehicular safety and high-

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Preventing Childhood Obesity: Health in the Balance BOX 1-1 Ten Great Public Health Achievements United States, 1900-1999 Vaccination Motor vehicle safety Safer workplaces Control of infectious disease Decline in deaths from coronary heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard SOURCE: CDC, 1999. way improvements have enabled us to make great progress in reducing motor vehicle deaths from this peak (Bolen et al., 1997; NSC, 1997). As the number of miles driven in the United States rose from 206 billion in 1930 to 2,467 billion in 1996, the death rate per 100 million miles declined dramatically from 15.97 in 1930 to 1.76 in 1996 (NSC, 1997; IOM, 1999). Even with this progress, however, we continue to record over 42,000 deaths a year from motor vehicle collisions (U.S. Department of Transportation, 2004). Early in the 20th century, when cigarettes were hand-rolled, few would have predicted that cigarette smoking would become the major preventable cause of death in the United States a century later. Tobacco reform efforts can be traced back to the late 19th and early 20th century and were strengthened in the 1940s and 1950s as epidemiological studies began to convince the medical community and public about the health hazards of tobacco (Fee et al., 2002). In 1964, nearly 70 million people in the U.S. consumed tobacco on a regular basis; and according to the 1955 Current Population Survey, two-thirds of men (68 percent) and one-third of women (32.4 percent) 18 years and older were regular smokers of cigarettes. As revealed by these data, cigarette smoking was the social norm, its link with heart and lung diseases was not widely accepted, and the desire or ability to quit smoking in that era was very low (DHHS, 1964). The reduction in national prevalence of cigarette smoking from 41.9 percent in 1965 to 23 percent in 2001 (Kochanek and Smith, 2004) reflects changes in the social norms and the positive influence of public health and policy interventions (Public Health Service, 1994; Economos et al., 2001).

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Preventing Childhood Obesity: Health in the Balance Recently, intensive effort has been devoted to reviewing the evidence of the effectiveness of community preventive services. The Guide to Community Preventive Services (Task Force on Community Preventive Services, 2004) has completed an analysis of the evidence in nine major areas (two health behaviors, six specific health conditions, and one addressing the social environment). Additional reports, including those central to preventing childhood obesity (e.g., school-based programs, community fruit and vegetable consumption, consumer literacy, and food and nutrition policy) are forthcoming. In the nine health areas examined to date, the Task Force found that certain categories of interventions appear to have strong evidence of effectiveness for multiple health behaviors and problems (Table 1-3). Further, based on the experience to date from the Guide TABLE 1-3 Recommended Public Health Interventions Common to Multiple Health Behaviors and Conditions Type of Intervention Health Behavior or Condition Community-wide campaigns Physical activity** Motor vehicle occupant injuries* Oral health (water fluoridation)** School-based interventions Physical activity** Oral health (sealants)** Vaccine preventable diseases (requirement for school admission)* Skin cancer* Mass media strategies Tobacco initiation and cessation** Motor vehicle occupant injuries** Laws and regulations Reducing exposure to secondhand smoke** Motor vehicle occupant injuries** Provider reminder systems Vaccine preventable diseases** Tobacco cessation* Reducing costs to patients Tobacco cessation* Vaccine preventable diseases** Home visits Vaccine preventable diseases* Violence prevention** * Sufficient Evidence. ** Strong Evidence. SOURCE: Task Force on Community Preventive Services, 2004.

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Preventing Childhood Obesity: Health in the Balance to Community Preventive Services, it appears that comprehensive programs that involve communities, schools, mass media, health providers, and laws and regulations are most likely to be effective for a number of health problems (see also Appendix D). There is a general pattern to the interventions that have successfully addressed many of these public health problems (CDC, 1999). In nearly all cases, policy changes were followed by the emergence of new government leadership structures to effectively enforce the policies and oversee the development and implementation of pertinent programs. Such direction was aided by improved surveillance methods, control measures, technologies, and treatments, together with expanding systems of service delivery and provider education. By organizing the experiences, principles, and strategies underlying these multiple achievements into conceptual frameworks, we may likewise develop successful approaches to childhood obesity prevention. SUMMARY After working throughout the 20th century to improve children’s physical health by reducing the incidence of disease and widening margins of safety, we now find ourselves bringing children into environments with some decidedly less-than-healthful features—fewer opportunities to be physically active and socially interactive, more opportunities to be sedentary and passively entertained, and frequent temptations to consume in the absence of hunger or need and to engage in other risky behaviors. A complex of interacting cultural, social, economic, familial, and psychological issues have set the stage for these growing obesity risks for children. Although the need to take action to curb the epidemic is widely acknowledged, the debate about what to do and how to do it is just beginning in earnest. Important insights can potentially be obtained from an examination of past successes in overcoming, or at least alleviating, some other problems that also seemed insurmountable at first. Such insights are presented as part of the committee’s charge to use theoretical and empirical findings to assess the potential utility of specific approaches within a comprehensive childhood obesity prevention strategy. This report provides a broad-based examination of the problem of obesity in children and youth, and it presents an action plan—with recommendations on the roles and responsibilities of numerous stakeholders and many sectors of society—for addressing this problem. The committee hopes that the report will produce shared understandings and stimulate sustained societal and lifestyle changes so that the current obesity trends among our children and youth may be reversed.

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