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Preventing Childhood Obesity: Health in the Balance 3 Developing an Action Plan The committee was charged with developing an action plan focused on preventing obesity in children and youth in the United States. The aim of the plan was to identify the most promising approaches for prevention, including policies and interventions for immediate action and in the longer term. The critical elements of the action plan’s development, described in this and subsequent chapters, were as follows: Clarifying definitions related to key concepts Developing a framework to guide the type and scope of data gathered Articulating obesity prevention goals for children and youth Identifying criteria for conducting an in-depth review of the available evidence Translating the findings from the best available evidence into specific recommendations that comprise an integrated action plan. DEFINITIONS AND TERMINOLOGY Childhood and Adolescent Obesity Body mass index (BMI) is an indirect measure of obesity based on the readily determined measures of height and weight. This report uses the term “obese” to refer to children and youth with BMIs equal to or greater than the 95th percentile of the age- and gender-specific BMI charts developed by
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Preventing Childhood Obesity: Health in the Balance the Centers for Disease Control and Prevention (CDC) (Kuczmarski et al., 2000). In most children, values at this level are known to indicate excess body fat, which itself is difficult to measure accurately in either clinical or population-based settings. What constitutes “excess” is an amount of body fat (often expressed as a percentage of body mass) that is sufficient to cause adverse health consequences. The exact percentage of body fat at which adverse consequences occur can vary widely across individuals and the consequences themselves—ranging from low self-esteem or mild glucose intolerance to major depression or nephropathy—show considerable variation as well. BMI—calculated as weight in kilograms divided by the square of height measured in meters (kg/m2)—is the recommended indicator of obesity-related risks in both children and adults. For adults, overweight is defined as a BMI between 25 and 29.9 kg/m2 and obesity is defined as a BMI equal to or greater than 30 kg/m2 (NHLBI, 1998). The BMI cut-off points were based on epidemiological data that show increasing mortality above a BMI of 25 kg/m2, with greater increases above 30 kg/m2 (NHLBI, 1998). Because children’s development varies with age, and because boys and girls develop at different rates, the use of BMI to assess body weight in children requires growth and gender considerations. Thus, BMI values for children and youth are specific to both age and gender (Barlow and Dietz, 1998; Dietz and Robinson, 1998). The committee recognizes that it has been customary to use the term “overweight” instead of “obese” to refer to children with BMIs above the age- and gender-specific 95th percentiles (Himes and Dietz, 1994; Barlow and Dietz, 1998; DHHS, 2001a; Kuczmarski et al., 2002; AAP, 2003). Obese has often been considered to be a pejorative term, despite having a specific medical meaning. There have also been concerns about misclassification, as BMI is only a surrogate measure of body fatness in children as in adults. Furthermore, children may experience functional impairment (physical or emotional) at different levels of body fatness. However, the term “obese” more effectively conveys the seriousness, urgency, and medical nature of this concern than does the term “overweight,” thereby reinforcing the importance of taking immediate action. Further, BMI in children correlates reasonably well to direct measures of body fatness (Mei et al., 2002), and high BMIs in children have been associated with many co-morbidities such as elevated blood pressure, insulin resistance, and increased lipids (Freedman et al., 2001). These are the same co-morbidities that often worsen in adult life and contribute to premature death from obesity. The committee recognizes, however, that the term obese is probably not well suited for children younger than 2 years of age because the relationships among BMI, body fat, and morbidity are less clear at these ages.
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Preventing Childhood Obesity: Health in the Balance Additionally, a high BMI in children younger than 2 years of age is less likely to persist than a high BMI in older children (Guo et al., 1994). BMI reference values are not established for children less than 2 years of age. Weight-for-length greater than the 95th percentile is used by CDC and the Special Supplemental Nutrition Program for Women, Infants, and Children to define overweight for children in this age group. It is important that government agencies, researchers, health-care providers, insurers, and others agree on the same definition of childhood obesity. Although varying definitions have arisen from many uses of the term in public health, clinical medicine, insurance coverage, government programs and other settings, to the extent possible, there should be concurrence on definitions and terminology. In this report, the term “obese” refers to children and youth between the ages of 2 and 18 years who have BMIs equal to or greater than the 95th percentile of the age- and gender-specific BMI charts developed by CDC.1 Prevention To “prevent” means simply to take prior anticipatory action to hinder the occurrence of a course or event. Prevention efforts related to health traditionally have focused on preventing disease, particularly infectious disease. Conceptual frameworks have been developed that categorize health-related prevention efforts based on the segment of the population to which they are directed: the entire population (universal or population-based prevention); those who are at high risk of developing a disease (selective or high-risk prevention); or those who have a disease (targeted or indicated prevention) (Gordon, 1983; Rose, 1992; IOM, 1994; WHO, 2000). Another traditional approach categorizes prevention according to disease progression: primary prevention involves avoiding the occurrence of a disease in a population; secondary prevention is aimed at early detection of the disease to limit its occurrence; and tertiary prevention is focused on limiting the consequences of the disease (DHHS, 2000). A more recent framework conceptualizes a spectrum of prevention based on where—from the individual to the broader environment—the prevention actions are directed. Approaches include strengthening individual knowledge and skills, providing community education, educating 1 This definition is consistent with current CDC recommendations with the exception of the terminology. International references such as the International Obesity Task Force or Cole BMI values allow for cross-cultural comparisons. These references use different populations and slightly differing techniques for developing cut-off points (Flegal et al., 2001).
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Preventing Childhood Obesity: Health in the Balance providers, fostering coalitions and networks, changing institutional practices, and influencing policy (Cohen and Swift, 1999). The prevention frameworks discussed lend themselves relatively easily to infectious diseases in which there are clear endpoints and progressions. But the frameworks can be more complex to apply to health outcomes (e.g., childhood obesity) in which the progression is a continuum and the condition is both a risk factor for other chronic diseases and a health outcome in itself. The committee concluded that the well-established concept of primary prevention was most amenable to its assigned task of developing a broad-based action plan that addresses the social, cultural, and environmental factors associated with childhood obesity. A primary prevention approach emphasizes efforts that can help the majority of children who are at a healthy weight to maintain that status and not become obese. Within this approach, the committee developed the majority of its recommendations as “population-based” actions—directed to the entire population instead of high-risk individuals. However, the committee acknowledges that obesity prevention will need to combine population-based efforts with targeted approaches for high-risk individuals and subgroups. Consequently, the report also contains specific actions aimed at high-risk populations affected by obesity, such as children and adolescents in particular ethnic groups with higher than average obesity-prevalence rates and communities in which there are recognizable social and economic disparities. Subpopulations of children warranting special consideration also include children with disabilities or special health-care needs. The complex medical, psychological, physical, and psychosocial difficulties that these children encounter may well put them at elevated risk for low physical activity levels and unhealthful dietary behaviors. The committee acknowledges that although population-based prevention approaches may be theoretically or conceptually the most useful approaches for addressing a society-wide problem, the practical challenge is in determining how best to implement these interventions to achieve broad outreach and maximal coverage. These issues will be discussed further in the sections on local communities and evaluation of interventions (see Chapters 4 and 6). The committee was not charged with, nor did it develop, recommendations directed specifically at obesity treatment or reducing excess weight in children and youth. However, it is likely that many of the suggested actions will also benefit children and youth who are already obese, even if the interventions are insufficient to produce enough short-term weight loss for achieving normal weight status. For example, obese children can benefit from healthful choices in the school cafeteria. Prevention of obesity, particularly among those at high risk, may seem very similar to treatment in that screening is involved and individualized
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Preventing Childhood Obesity: Health in the Balance intervention is often delivered in clinical settings. However, there are several important differences between prevention and treatment approaches (Kumanyika and Obarzanek, 2003). The targeted outcomes are different: prevention of weight gain is a satisfactory outcome for prevention approaches, whereas weight loss is the desired outcome for treatment. Motivations to maintain a healthful rate of weight gain for growing children may differ in nature and intensity from motivations to lose weight. Although treatment approaches may include relatively extreme behavioral changes over the short term, preventive strategies usually necessitate long-term continuation. The committee’s approach to obesity prevention is similar to the range of prevention efforts that have been used to address many other public health problems. Some efforts directly change the physical environment but require no purposeful action on the part of the target population (e.g., fluoridation of community drinking water and food fortification); others directly require behavior change in targeted high-risk populations (e.g., immunization of children); and some require environmental change to facilitate behavioral change (e.g., zoning and land-use regulations to encourage physical activity). The majority of efforts require multiple approaches; for example, efforts to reduce underage drinking and tobacco control have involved legislation, media campaigns, counseling, and many other mechanisms (NRC and IOM, 2003; Mensah et al., 2004). Appendix B provides a glossary of terms used throughout this report. FRAMEWORK FOR ACTION Using an ecological perspective, the committee developed a framework to depict the behavioral settings and leverage points that influence both sides of the energy balance2 equation—energy intake and energy expenditure. An ecological systems theory model postulates that changes in individual characteristics are affected not only by personal factors (e.g., age, gender, genetic profile) but also by interactions with the larger social, cultural, and environmental contexts in which they live (e.g., family, school, community) (Figure 3-1) (Davison and Birch, 2001; Lobstein et al., 2004). Building on this ecological model and drawing upon concepts from several relevant frameworks (Swinburn et al., 1999; Booth et al., 2001; Kumanyika et al., 2002; Swinburn and Egger, 2004), the committee developed a framework that shows layers of ecologic factors as influences on energy imbalance, which is shown as the typical graphic in which energy 2 Energy balance, as discussed in detail below, refers to a state in which energy intake is equivalent to energy expenditure, resulting in no net weight gain or weight loss.
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Preventing Childhood Obesity: Health in the Balance FIGURE 3-1 Simplified ecological systems theory model. intake exceeds energy expenditure (Figure 3-2). Both aspects of energy imbalance (i.e., food and beverage intake and physical activity) interact with and are affected by multiple factors within each of the four ecological layers. The two innermost layers describe factors operating within the individual (including genetic factors, ethnic identity and culturally determined attitudes and beliefs, psychosocial factors, and current health status) and those operating within the physical and social locations and situations that define daily behavioral settings (Booth et al., 2001). The key behavioral settings for children and youth are the home, school, and community. As noted in the framework developed by the Partnership to Promote Healthy Eating and Active Living, behavioral settings are affected either directly or indirectly by a variety of other factors that potentially constitute primary and secondary leverage points for effecting changes (Booth et al., 2001). These leverage points include the major sectors that affect the food system, opportunities for physical activity or sedentary behavior, and information and education regarding dietary behaviors and physical activity. The outermost layer on the framework in Figure 3-2 reflects the critical concept of an overlay of social norms and values, that is, the social fabric that cuts across all the layers and processes below. Social norms and values both determine and respond to collective social and institutional processes within the con-
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Preventing Childhood Obesity: Health in the Balance FIGURE 3-2 Framework for understanding obesity in children and youth. NOTE: In this diagram energy intake is depicted as excessive when compared to energy expenditure, leading to a positive energy balance (or energy imbalance) resulting in obesity. text of the larger U.S. culture. This framework, which emphasizes the need for obesity prevention efforts to leverage the interests and actions of a number of stakeholders working within and across multiple settings and sectors, guided the review of evidence and the development of recommendations in this report.
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Preventing Childhood Obesity: Health in the Balance OBESITY PREVENTION GOALS Clear specification of obesity prevention goals is essential in shaping an action plan and evaluating its success. Pertinent issues for setting obesity prevention goals for populations include concepts of optimum population BMI and healthy weight levels, potential effects on food intake and patterns of physical activity and inactivity (the primary modifiable determinants of obesity), as well as attitudes and social norms related to food and eating, physical activity and inactivity, body size, and dietary restrictions (WHO, 2000; Kumanyika et al., 2002). For children and youth, these considerations must be framed not only within the context of healthy physical, psychological, and cognitive development but in recognition that the increased prevalence of childhood obesity has broadened the emphasis of dietary guidance to address the overconsumption of energy-dense foods and beverages and physical activity patterns (ADA, 2003, 2004). For individual children and youth, obesity prevention goals focus on maintaining energy balance (calories consumed versus calories expended). As discussed in greater detail later in the chapter, this involves engaging in healthful dietary behaviors and regular physical activity. Healthful dietary behaviors include choosing a balanced diet, eating moderate portion sizes, and heeding the body’s own satiety cues that indicate physiological fullness. It is currently recommended that children and adolescents accumulate a minimum of 60 minutes of moderate to vigorous physical activity each day (see section on physical activity). Children’s food and beverage intake and their physical activity and sedentary behavior patterns can be influenced by a variety of environmental factors, including the availability and affordability of healthful foods, advertising messages, and opportunities to participate in physical activity within communities (Richter et al., 2000). Although individuals and families are embedded within broader social, economic, and political environments that influence their behaviors and may either promote or constrain the maintenance of health (IOM, 2001), such environments may also serve as contexts for change. These are the settings in which relationships are formed (e.g., home environment and support networks), and they represent a collection of formal and informal community institutions that monitor the behavior and safety of residents (Leventhal and Brooks-Gunn, 2001). As will be noted throughout this report, changing the social, physical, and economic environments that contribute to the incidence and prevalence of childhood obesity—especially in populations in which the problem is longstanding and highly prevalent—may take many years to achieve. Therefore, the committee acknowledges that numerous intermediate goals, involving step-by-step improvements in diet patterns and physical activity levels of children and youth, are necessary for assessing progress. The ulti-
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Preventing Childhood Obesity: Health in the Balance BOX 3-1 Goals of Obesity Prevention in Children and Youth The goal of obesity prevention in children and youth is to create—through directed social change—an environmental-behavioral synergy that promotes: For the population of children and youth Reduction in the incidence of childhood and adolescent obesity Reduction in the prevalence of childhood and adolescent obesity Reduction of mean population BMI levels Improvement in the proportion of children meeting the Dietary Guidelines for Americans Improvement in the proportion of children meeting physical activity guidelines Achieving physical, psychological, and cognitive growth and developmental goals For individual children and youth A healthy weight trajectory, as defined by the CDC BMI charts A healthful diet (quality and quantity) Appropriate amounts and types of physical activity Achieving physical, psychosocial, and cognitive growth and developmental goals Because it may take a number of years to achieve and sustain these goals, intermediate goals are needed to assess progress toward reduction of obesity through policy and system changes. Examples include: Increased number of children who safely walk and bike to school Improved access to and affordability of fruits and vegetables for low-income populations Increased availability and use of community recreational facilities Increased play and physical activity opportunities Increased number of new industry products and advertising messages that promote energy balance at a healthy weight Increased availability and affordability of healthful foods and beverages at supermarkets, grocery stores, and farmers markets located within walking distance of the communities they serve Changes in institutional and environmental policies that promote energy balance mate aim of obesity prevention in children and youth, however, is to create, through directed social change, an environmental-behavioral synergy that promotes positive outcomes both at the population and individual levels. Box 3-1 summarizes these long-term and intermediate goals, which will be discussed in greater detail throughout the report.
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Preventing Childhood Obesity: Health in the Balance Optimum BMI and Healthy Weight The concept of optimum BMI can be applied to populations. For countries such as the United States, where undernutrition is not as common as in developing countries,3 a BMI-distribution median of around 21 kg/m2 may be optimal (WHO, 2000). Population weight goals for obesity prevention in adults can also be stated in terms of decreasing the proportion that exceed the threshold of 30 kg/m2, although this goal includes both preventing new cases of obesity and reducing weight among those already over the threshold. The same principles are appropriate for assessing the population of children in the United States in pursuit of the committee’s primary objective: to stop, and eventually reverse, current trends toward higher BMI levels. Also, as discussed in Chapter 2, there are particular concerns about the population of obese children becoming heavier. Achieving this objective would have the effects of reducing the mean BMI as well as decreasing the proportion of children and youth in the population that exceeds the threshold definition of obesity. Available research does not currently allow the committee to define an optimum BMI for children and youth. It suggests, however, that future research toward this aim should be focused on defining the associations between BMI and objective measures of concurrent and future growth and between BMI and physiological and psychological morbidity, mortality, and health (Robinson, 1993; Robinson and Killen, 2001). Analogous to the current practice for adults, the committee recommends the use of BMI for assessing individual and population changes in children and youth over time and in response to interventions. Population weight goals for childhood obesity prevention should be stated in terms of changes in the mean BMI and in the shape of the entire BMI distribution. Alternatively, goals can be stated in terms of decreasing the proportion of children or youth who exceed particular thresholds—e.g., 75th, 85th, 90th, 95th, or 97th percentiles of BMI for age and gender on the CDC BMI charts. In the absence of an appropriate evidence base, however, threshold goals are necessarily somewhat arbitrary and sacrifice substantial information about the rest of the distribution as well as substantial statistical power to detect differences between groups and over time (Robinson and Killen, 2001). 3 Hunger and food insecurity persist in the United States. In 2002, 35 million individuals including 13.1 million children lived in food insecure households (an estimated 11 percent of all U.S. households); 3.5 percent (3.8 million) of U.S. households were food insecure with hunger (Nord et al., 2003). Additionally, rates of micronutrient deficiencies remain unacceptably high in certain subgroups of the U.S. population (Wright et al., 1998; Ballew et al., 2001; Ganji et al., 2003; Hampl et al., 2004).
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Preventing Childhood Obesity: Health in the Balance The current CDC guidelines for healthy weight in children and youth are in the range of the 5th to 85th percentiles of the age- and gender-specific BMI charts. Therefore, a child whose weight tracks in that range—that is, he or she does not cross to lower than the 5th or higher than the 85th percentiles—would be considered to be in the healthy weight range according to these definitions. The CDC BMI charts are mathematically smoothed curves of the pooled growth parameters of children and adolescents sampled in cross-sectional national health surveys conducted from 1963 to 1994. An analogy would be to consider the curves as compiled from a series of “snapshots” of large national samples made at different times over three decades. But because the sample sizes at each age level get much smaller at the extremes of the distributions, the growth curves may be more prone to errors at the upper and lower ends. Because of the increases in body weight that occurred in the 1980s and 1990s—after the second National Health and Nutrition Examination Survey (NHANES II) conducted in 1976-1980—a decision was made not to include the NHANES III (1988-1994) body-weight data in the revised 2000 BMI charts for children aged 6 years or older. The NHANES III data would have shifted the affected curves (weight-for-age and BMI-for-age) upward, which was considered to be biologically and medically undesirable. However, the fact that the CDC BMI charts were developed from data for a prior time period in which children were leaner, on average, leads to an occasionally confusing situation—for example, where more than 5 percent of the population is above the 95th percentile—but this is readily clarified in the context of the charts’ historical source. The CDC BMI charts are derived from cross-sectional samples of children (data for different age groups are based on different children). That is, they do not directly represent the longitudinal growth trajectory for the same set of children who have been measured as they age.4 Therefore, it is not known whether an individual child’s height, weight, or BMI should be expected to follow along the same percentile curve over time in order to maintain health or whether there are health implications of variations throughout childhood (e.g., crossing percentiles by going from the 20th percentile at age 1 to the 60th percentile at age 5 to the 40th percentile at age 12). Mei and colleagues (2004) found that shifts in growth rates were 4 The latter approach has been used to develop longitudinal growth charts that are used in several other countries (Tanner and Davies, 1985; Cameron, 2002). These types of charts are generally developed from smaller, and potentially less representative, samples.
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Preventing Childhood Obesity: Health in the Balance This has been exemplified by programs that reduce television viewing time and decrease BMI in children (Robinson, 1999). Given the significant shortage at present of experimental evidence to guide programs and policies, and the fact that many societal variables of interest have not been well addressed in controlled experimental studies as moderating or mediating factors, obesity prevention will require an evidence-based public health approach that continues to draw on RCTs, quasi-experiments, and observational studies as important sources of information (Victora et al., 2004). Given that obesity is a serious health risk, preventive actions should be taken even if there is as-yet-incomplete scientific evidence on the interventions to address specific causes and correlates of obesity. However, there is an obligation to accumulate appropriate evidence not only to justify a course of action but to assess whether it has made a difference. Finally, for interventions that have minimal potential risk and require few resources, formative and process evaluations may be sufficient to provide a “preponderance” of evidence (Robinson et al., 1998). As described in Appendix C, the committee conducted a thorough bibliographic search of the relevant scientific databases and benefited from the expertise of academic, industry, government, and nonprofit sector experts during its deliberations. In examining the literature, the committee focused on studies that examined weight and body composition outcomes, but it also broadened its scope to include studies that looked at changes in physical activity (or sedentary behavior) levels and in dietary intake patterns. In examining the evidence on obesity-related prevention interventions, the committee considered the methodologies used by individual studies. Evaluating such studies involves characterizing the appropriateness of their designs for measuring target outcomes (e.g., increasing physical activity) as well as assessing the quality and generalizability of the study execution. The committee also considered the strength of the overall body of available evidence. Other factors considered by the committee included the feasibility of implementing the recommended actions, the opportunities for making changes, and the past success of parallel public health and social change efforts. Where trends of social, dietary, and other factors and health outcomes ran in parallel, the committee believes these trends merit further study and concern while acknowledging the possible occurrence of confounding. It is also important to note that the committee focused on areas for improvement rather than on specific products, mechanisms for distribution, or industries. For example, the report emphasizes the nutritional evaluation of the contents of vending machines in schools rather than the re-
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Preventing Childhood Obesity: Health in the Balance moval of vending machines (Chapter 7); considers the nutrient quality and energy density of foods and beverages rather than focusing on specific types of products (e.g., soft drinks, chips, candy); and highlights the improvements needed and actions that can promote energy balance rather than addressing any one industry (e.g., fast food restaurants). SUMMARY This report uses the term “obese” to refer to children and youth between the ages of 2 and 18 years who have BMIs equal to or greater than the 95th percentile of the age- and gender-specific BMI charts developed by CDC. For individuals, obesity prevention involves maintaining energy balance at a healthy weight while protecting overall health, growth and development, and nutritional status. Energy balance (calories consumed versus calories expended) is an extraordinarily complex concept when considering the multitude of genetic, biological, psychological, sociocultural, and environmental factors that affect both sides of the energy balance equation and the interrelationships among these factors. Clear specification of obesity prevention goals is essential in shaping an action plan and evaluating its success. Relevant issues for setting obesity prevention goals for populations include concepts of optimum population BMI and healthy weight levels, potential effects on food intake and patterns of physical activity and inactivity, as well as attitudes and social norms related to food and eating, physical activity, inactivity, body size, and dietary restrictions. This chapter discusses a variety of influences on children’s diets and physical activity patterns including genetic variation and biological considerations, and sociocultural and other environmental factors. Using an ecological systems theory model and a primary prevention evidence-based public health approach, this report focuses on how changes in the individual child’s behaviors are affected not only by individual factors but also through interactions with the larger social, cultural, and environmental contexts in which he or she lives (e.g., family, school, community, social and physical environments). REFERENCES AAP (American Academy of Pediatrics), Committee on Nutrition. 2003. Prevention of pediatric overweight and obesity. Pediatrics 112(2):424-430. ADA (American Dietetic Association). 2003. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J Am Diet Assoc 103(7):887-893. ADA. 2004. Position of the American Dietetic Association: Dietary guidance for healthy children ages 2 to 11 years. J Am Diet Assoc 104(4):660-677.
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