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The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth (2006)

Chapter: Overview of Preventing Childhood Obesity: Health in the Balance

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Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
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Overview of Preventing Childhood Obesity; Health in the Balance

Jeff Koplan


DR. KOPLAN: Thank you very much, Dr. Fineberg. Thank you all for coming out in inclement conditions and spending some time with us to talk about what we think is an important subject. I am sure you think it is important as well; it is the reason you are here.

We are calling this a lecture, and it is officially a lecture, but it is really a group of speakers sharing thoughts. We would like your active involvement in the discussion afterward as well.

Looking around this crowd, I see people with true expertise in this field and in germane fields as well. I think such a mix will enrich our evening, and we hope to have plenty of time for everyone to ask their questions before the evening is over.

I want to review the nature of this obesity epidemic in children, some of the factors that put us where we are, and then I want to spend some time discussing the report’s recommendations for leading us out of this problem we’ve found ourselves in and what we need to do to reverse the epidemic.

I think a striking aspect of the epidemic of obesity in children is that for most all of our lives we have lived in a period of continual advances in health and health outcomes, both for children and adults.

We have had intermittent setbacks, some of them major, such as the ongoing HIV/AIDS epidemic. There are, obviously, problems that we have not yet conquered, but overall, our life span and our quality of life has, for the most part, increased, and increased in a rather remarkable way. You only have to think about

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
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vaccines and their impact, seat belt use, the control of tobacco, fluoridated drinking water, and decreased infant mortality to realize the progress we have made. These improvements have all had huge impacts on our life span and our quality of life. Now we have an epidemic of obesity, which is unique and alarming.

If you will indulge me for a few moments as part of this discussion, I would like to reflect a bit on the concept of being healthy. Only recently do we have some kind of scientific parameters to offer for what healthy is, and we are still learning more about how to better define this. The concept of being healthy has changed remarkably over many decades, largely based on a mixture of unscientific opinion, cultural preferences (our people do this and that is why we are healthy), and occasional elements of data and fact. What does healthy mean in terms of where we live and how we live, what and how much we eat, how we look at ourselves, and how we look at others? This has been an evolving concept, and it continues to evolve.

Similarly, the concepts of overweight and obesity has been seen in different ways by different cultures at different times. It is an aesthetic issue; in some cultures being overweight is seen as a sign of prosperity and well being, and in other cultures it is not. The concepts of health, obesity, and being overweight change with time and place.

Where we live and what makes our living environment healthy has shifted. There was a time when cities were seen as the least healthy of places to live: too much smoke, overcrowding, inadequate sewage and water facilities, and so on. People started moving to the suburbs because they were seen as being more healthy. But one of the things we will talk about is the built environment: living in the suburbs may now be far less healthy, at least in terms of physical activity, than living in the city. The suburbia of Leave It to Beaver and Father Knows Best is not the suburbia that is currently being developed. The structure and the nature of community affect the health habits that directly lead to childhood obesity.

Diet has obviously changed as well. A healthy diet in 1900 on a farm in Wisconsin would not seem very healthy to us today:

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

lots of whole fat dairy, lots of red meat, bacon, eggs, and so on. It is making me hungry.

Now, I would like to use my own exemplary youth as an illustration to help you reflect on how our life styles have changed. I would urge you just to think about your own growing up and some of these changes that have occurred since then.

It is not so much what we did, but the elements of the American lifestyle have changed and have contributed to where we are now in this epidemic.

Growing up in the 1950s, I lived in a suburban neighborhood of Boston. In this neighborhood the streets were laid out in a grid, and sidewalks ran on both sides of the street. The neighborhood was near a golf course that was used for outdoor activities.

All throughout our school lives, we walked to school in relative safety. Car pools were an unknown commodity in our community, and there was no busing to school.

Gym class, unfortunately, was a regular part of our school days. I detested gym and, to this day, I don’t see what climbing a rope to the ceiling of the gym has to do with fitness. I thought gym class was made to torture students, of which I was one. I abhorred it and feared it every day.

We had recess and played games. Even though I was one of the last children picked for all sports teams, I have retained an interest in physical activity.

We walked to and from school, and to and from the library, and used public transportation. In fact, by fifth and sixth grade my parents let me take public transportation all over Boston.

From where we lived south of Boston, I would walk to a bus stop, take a bus to Matapan, pick up what is now the Red Line in the Boston subway system, take it into downtown Boston, wander around all day, and come back the same way. This makes the point of how using public transport is healthy. The people who promote public transport are partners with us in public health in promoting physical activity and combating obesity.

When I was in Boston, I went looking for stamps on Bromfield Street, which I collected. Every trip I couldn’t help but stop at

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

Little Jack Horner’s Joke Shop for the latest hand buzzer and whoopee cushion.

The children in the neighborhood were of various shapes, sizes and interests, but after school everyone was outside. There was nothing to do in the house. Children went outside. I want to emphasize that I was not an athletic child; you know the type, glasses in the third grade, bookish, not excelling in sports. It didn’t matter. Everybody went outside, and you stayed out until it was dark. In the winter, we played in the snow and threw snowballs and built forts and sledded. In the other seasons, we got into trouble at building sites, trespassing, and generally creating mayhem. In any event, we were outside, and it wasn’t like our parents were saying, “You have to stay in.” When we came in, we were usually tired, and it was just time to eat when we came through the door.

I am not trying to paint this as an idyllic, wonderful time. I think many things are much better today than they were then. What I’ve just described are features of society and life from 50 years ago that are different now. You can begin to see, as you think of your own times and things you did, how society and the culture were different, and how some of the changes that have occurred might contribute to an epidemic of obesity.

A highlight of my youth was being named to the safety patrol in the sixth grade. My single duty was to walk around and make sure the other children walked to school safely. I can still remember that I was given a special belt. I put it on and was really excited. I haven’t seen one of those white belts in years. I think they are used as trusses in the hospital now where I work.

Our television was a 7-inch Philco. There were a couple of hours of programming a day to watch. No DVDs, no CDs, nothing. We also had a radio for music and such. There was never any competition between watching or listening and doing other things.

The diet I described for that farm in Wisconsin was not much different from the diet in our home. If someone were to say to my mother, “Why isn’t there margarine in the refrigerator?” do you think she would have said, “I don’t care for trans-fatty acids”? She didn’t know anything about trans-fatty acids.

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

There was little snacking. For one, there were very few commercial products for snacking and, in addition, they just weren’t in the house. Carbonated, sweetened beverages were not part of our daily life. There were treats to be had at some places and at some times, and when you had them, the portion sizes were much smaller than today’s—the Pepsis were 8 ounces and no more. If you went to a movie, the popcorn serving you had was a couple of cups. It wasn’t the 20 gallon bucket that is served today.

People make a point about cultures and how some cultures are at odds with issues that would promote leanness and physical activity. This is not unique. I come from a culture, basically middle European Jewish, in which eating is a way in life and social events involved eating. My culture had a starvation background. Every time my grandmother saw me, even if she had seen me five minutes before, she would say, “You are so thin. You need to eat something.”

“But Grandma,” I’d say, “I just ate!”

“It doesn’t matter,” she’d say. “I made this for you special.”

In many of our traditions there are some long-standing issues about both physical activity and food. Physical activity was not encouraged by my family and the culture. In fact, some members of my family considered sweating to be a preterminal event.

The result of all these social and characteristics of the times was that we ended up having lots of activity in our lives. Our community was designed, unintentionally, in a relatively healthy way to promote that. But there was lots of eating, and many of our concepts about food and diet were not particularly healthy ones, even then.

There wasn’t an epidemic of obesity at that time. That epidemic, as Dr. Dietz will show during his talk, has occurred in a very short period of time in a very dramatic fashion.

I think, for all of us, it has been a learning experience over the last decade or so to realize that weight has a significant negative impact on a wide range of health parameters. It has also been a shock to realize that all segments of our population are becoming increasingly obese, especially children, and this change has occurred in an epidemic manner

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

Myself and other epidemiologists don’t use the term epidemic lightly. If an epidemic is defined as an unpredicted and unexpected increase in the occurrence rate of a certain illness, then obesity is clearly an epidemic and continues to be one.

Obesity has crept up on us as a major public health problem, and it has left us, unfortunately in many instances, seeking simple and uni-dimensional causes and, thus, answers to the problem. We have seen frequent articles in the press or scientific papers that would make the case that one element or another is the cause of the obesity epidemic: carbonated, sugared beverages, vending machines, lack of physical education, nontraditional family structures, El Niño, liberals, immigration, or whatever. Actually, as the report emphasizes, the obesity epidemic is a multifactorial problem.

We have developed what is, in many ways, an unhealthy environment for children to grow up in: not enough physical activity and a poor diet. This is a striking difference from the trend in health over the last 100 years. We have made great strides toward promoting health and having a healthier environment for our children, whether it is in regard to safety, nutrients, or a wide range of things. We have failed in this particular regards, with dire outcome.

What has changed in the last 30 years? American society and American lifestyles have changed. Portion sizes are larger. Families are eating more meals outside the home and fewer meals together at a table. There are more televisions and video games in the average home. More time is being spent sitting in front of a screen. Children are not walking or biking to schools with the same frequency. There is no physical education in many schools. The changes in the types of foods and beverages being offered, promoted, and consumed are remarkable, and this is true in schools as well. There are competitive food options in schools that did not previously exist.

These are considerable changes in the lifestyle, environment, and behaviors of children, and they have had the impact that we are talking about today.

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

One of our society’s reactions has been a certain sense of helplessness, not so much for the individual, but for the problem as a whole, a feeling like “There is nothing we can do;” “This is the way modern life is;” or “This is beyond our control.”

I think such helplessness is one of the things this report can remedy, because such statements of futility are just not true. There is plenty we can do.

We have a track record of over 100 years of public health that proves we can solve what previously seemed to be insurmountable problems. When we grew up, there were no seat belts in cars; there was no sense of safety. Drinking and driving was simply considered the way you sometimes drove. Those concepts have been changed, and with remarkable differences in health outcomes. Tobacco is another example. If you were to examine the early days of anti-tobacco efforts, you would see the same kind or reactions we get now when we talk about childhood obesity: “Americans like to smoke;” “It is part of our culture;” “It is part of our economy;” “There are huge economic forces against it;” “That is just the way life is here;” or “You are trying to alter our sociocultural values by combating smoking.”

You will hear the same thing about the obesity epidemic, and we all should reject such statements. There are things that we can and will do about obesity. And the sooner we do it, the better. That is what this report is about. It is to set a blueprint for all our efforts to come. I want to briefly mention some ideas in the report. You will hear about them in much greater detail from our panelists.

One of these ideas is the nature of the epidemic. As Dr. Fineberg said, it is a doubling and, in some age groups, a tripling of obesity in children. It is an outbreak that occurs across the nation. No region is safe from it. It occurs in all ethnic and racial groups. It occurs in all ages. We are focusing on children, but it occurs in all ages. It is rampant and growing at a remarkable rat, as Dr. Dietz will show in his slides.

The committee’s approach was to gather as much evidence as possible, assemble it in a range of different subtopics around obesity, and sum everything up with a set of recommendations for how to deal with the epidemic.

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

I think a striking aspect of the report is that we identified what is known, and we identified what is not known but would be helpful to know, but we didn’t limit our recommendations by saying, “Until we learn about this, we can’t do anything.” We rejected that as being an irresponsible approach. Being responsible means we have to act as if there were a SARS epidemic starting in this community: we don’t know much about SARS, but we have to take some steps to combat it.

What we don’t know about the childhood obesity epidemic we will learn as we make attempts to deal with it. We will make improvements as we go along. That is why careful evaluation is a feature of everything we advocate.

There are many recommendations in the Institute of Medicine’s (IOM’s) report for stakeholders. There are recommendations for parents and families: encourage children to engage in regular physical activity, provide them with healthy foods, and serve as good role models. We recommend that parents limit TV and other recreational screen time to no more than two hours a day.

There are recommendations for schools, from preschool through high school. They should implement nutritional standards, set at the national level, for all foods and beverages served on school grounds, including those dispensed from vending machines. Schools should also expand opportunities for their students to engage in at least 30 minutes of moderate to vigorous physical activity every day.

The report calls on the food, beverage, and entertainment industries to develop innovations related to healthier food and beverages. The report calls for changes in packaging and providing clear and consistent media messages about the energy contents. Further, the report calls for the relevant industries to voluntarily develop and implement guidelines for advertising and marketing directly to children. There is some controversy over this. Some people feel that the industry is not going to make these changes on their own. Some members of our committee felt that way. Here is an opportunity to engage in a partnership, to encourage a collegial approach before resorting to more regulatory means. But, if necessary, regulations may be imposed overtime.

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

The report calls for a stronger role for community organizations and state and local governments. They should expand their programs and coordinate them with programs run by other organizations. These organizations can lead the way by looking at the built environment, including bike paths, sidewalks, and playgrounds, and make the necessary changes through capital investment and local zoning.

There is a huge economic play in this. We either make the investment up front, which would be relatively modest, or we will pay huge prices down the road in health care costs.

Of course, health care professionals have a role to play, much as they did in controlling tobacco or when pediatricians addressed injury prevention. There is a history of successful interventions by health care professionals, and we urge them to play an active role in combating the obesity epidemic.

The federal government must provide the leadership needed to make all this work. The federal government needs to go beyond rhetoric and allocate resources to fight this epidemic. Because so many departments of government will have important roles in combating this epidemic, coordinating the efforts of the departments of Transportation, Education, Defense, Housing and Urban Development, Health and Human Services, and others will be an absolute necessity.

There are no easy solutions to the problem of obesity. That is why the report is more than three or four pages long. Unfortunately, the danger of many recommendations is that everyone will wait for some other group to step forward and act. However, it is exciting to already see some of the activities and efforts that are underway, both before the report came out, and some that have begun since the report, particularly at the grassroots level.

It has helped that, much as we have made changes in the social norm and other aspects that have made our society healthier, the changes in the social norms will take place in food consumption and physical activity as well.

We will flesh out this overview of the report with more specific discussions from our panelists, and each will be providing a somewhat different perspective.

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×

My colleague on the report, introduced briefly by Dr. Fineberg, is Dr. Shiriki Kumanyika, an international expert in obesity. Dr. Kumanyika is a professor of epidemiology at the University of Pennsylvania. She is also associate dean for health promotion and disease prevention. She has been working in this area for years and has been a very effective person on a wide range of government panels, including U.S. dietary guidelines advisory committees, IOM’s Food and Nutrition Board, and the National Institutes of Health’s clinical obesity task force. She is a member of the IOM and was extraordinarily important in crafting the report. So, let me turn the podium over to Dr. Kumanyika.

Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
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Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
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Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
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Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
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Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
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Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
Page 10
Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
Page 11
Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
Page 12
Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
Page 13
Suggested Citation:"Overview of Preventing Childhood Obesity: Health in the Balance ." Institute of Medicine. 2006. The Richard and Hinda Rosenthal Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth. Washington, DC: The National Academies Press. doi: 10.17226/11477.
×
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In 1988, an exciting and important new program was launched at the Institute of Medicine (IOM). Through the generosity of the Richard and Hinda Rosenthal Foundation, a lecture series was established to bring to greater attention some of the critical health policy issues facing our nation today. Each year a subject of particular relevance is addressed through three lectures presented by experts in the field. The lectures are published at a later date for national dissemination.

The Rosenthal lectures have attracted an enthusiastic following among health policy researchers and decision makers, both in Washington, D.C., and across the country. Our speakers are the leading experts on the subjects under discussion and our audience includes many of the major policymakers charged with making the U.S. health care system more effective and humane. The lectures and associated remarks have engendered lively and productive dialogue. The Richard and Hinda Rosenthalk Lectures 2004: Perspectives on the Prevention of Childhood Obesity in Children and Youth captures a panel discussion on the IOM report, Preventing Childhood Obesity: Health in the Balance. There is much to learn from the informed and real-world perspectives provided by the contributors to this book.

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