2

Assessing the Current Situation

Key Messages

  Populationwide obesity has serious health, economic, and social consequences for individuals and for society at large.

  Almost one-third of children and two-thirds of adults in the United States are overweight or obese.

  Although the vast majority of people who are obese are not poor or racial/ethnic minorities, the percentage of people within poor and ethnic minority populations who are affected by obesity is relatively higher, sometimes markedly so, for one or both sexes compared with the nonpoor or whites. Particular attention to these high-risk groups is essential in obesity prevention efforts.

  Causes of the high rates of obesity can be traced to trends in environmental influences on physical activity and food intake.

  Important advances have occurred in national guidance, policy, research directions, and partnership initiatives, as well as consensus on the need for a broad, prevention-oriented approach to the obesity epidemic. However, direct opposition to some potential obesity prevention strategies impedes their acceptance and implementation.

  Evidence that levels of obesity may be stabilizing may be an important sign that these advances are having a positive effect. However, complex realities associated with the obesity epidemic give rise to several considerations— including some that can serve as major roadblocks—that must be addressed when measures are taken to accelerate preventive efforts.



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2 Assessing the Current Situation Key Messages • Populationwide obesity has serious health, economic, and social conse- quences for individuals and for society at large. • Almost one-third of children and two-thirds of adults in the United States are overweight or obese. • Although the vast majority of people who are obese are not poor or racial/ ethnic minorities, the percentage of people within poor and ethnic minority populations who are affected by obesity is relatively higher, sometimes markedly so, for one or both sexes compared with the nonpoor or whites. Particular attention to these high-risk groups is essential in obesity preven- tion efforts. • Causes of the high rates of obesity can be traced to trends in environmental influences on physical activity and food intake. • Important advances have occurred in national guidance, policy, research directions, and partnership initiatives, as well as consensus on the need for a broad, prevention-oriented approach to the obesity epidemic. However, direct opposition to some potential obesity prevention strategies impedes their acceptance and implementation. • Evidence that levels of obesity may be stabilizing may be an important sign that these advances are having a positive effect. However, complex realities associated with the obesity epidemic give rise to several considerations— including some that can serve as major roadblocks—that must be addressed when measures are taken to accelerate preventive efforts. 33

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T he process of developing strategies to accelerate obesity prevention begins with a situation assessment. This chapter provides such an assessment by present- ing data on the consequences the nation faces if the epidemic persists; the starting point for acceleration of preventive efforts with respect to obesity prevalence in the general population and in populations at particularly high risk; contributory trends related to physical activity, food intake, and media use and other factors relevant to sedentary behavior; and positive steps that have already been taken and have momentum, along with the roadblocks that could limit further advances. The nature of change trajectories needed to track progress toward the goal of see- ing obesity levels decline is also discussed. HUMAN AND SOCIETAL CONSEQUENCES OF THE OBESITY EPIDEMIC The consequences of today’s high rates of obesity have two broad dimensions. The first is the direct and sometimes devastating health and social consequences to individuals—the potential for illness or disability, social ostracism, discrimina- tion, depression, and poor quality of life. The second dimension encompasses the indirect effects of obesity on society, reflected in population fitness, health care costs, and other aspects of the economy. Human Costs As shown in Table 2-1, obesity is associated with major causes of death and disability, as well as with psychosocial consequences that impair functioning and quality of life. The effect of obesity in predisposing to the development of type 2 diabetes is particularly strong, so much so that the onset of this disease—formerly observed only in adults—also now occurs during childhood (CDC, 2011). Adverse effects are observed throughout the life course and may be transmitted from mother to child through the characteristics of the gestational environment (IOM, 2009). According to current estimates, one-third of all children born today (and one-half of Latino and black children) will develop type 2 diabetes in their life- time (Narayan et al., 2003). One dire projection is that obesity may lead to a generation with a shorter life span than that of their parents (American Heart Association, 2010; Olshansky et al., 2005). The highest prevalence of obesity-related conditions occurs in middle-aged and older adults, with direct effects on quality of life and on rates of disease, disability, and death at an early age. High blood pressure is the most prevalent of these con- Accelerating Progress in Obesity Prevention 34

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TABLE 2-1 Physical Health, Psychosocial, and Functional Consequences of Obesity Over the Life Course Physical Health Psychosocial Functional • Cardiovascular disease • Stigma • Unemployment • Cancer • Negative stereotyping • Mobility limitations • Glucose intolerance and insulin • Discrimination • Disability resistance • Teasing and bullying • Low physical fitness • Type 2 diabetes • Social marginalization • Absenteeism from school or • Hypertension • Low self-esteem work • Dyslipidemia • Negative body image • Disqualification from active • Hepatic steatosis • Depression service in the military and • Choleslitasis fire/police services • Sleep apnea • Reduced productivity • Reduction of cerebral blood flow • Reduced academic • Menstrual abnormalities performance • Orthopedic problems • Gallbladder disease • Hyperuricemia and gout SOURCE: Adapted from IOM, 2010a. ditions, and is a major risk factor for cardiovascular diseases. High blood pressure affects a third of U.S. adults aged 20 and over and more than half of adults aged 55 and older. Together high blood pressure, coronary heart disease, heart failure, and stroke affect 37 to 39 percent of women and men aged 40 to 59 and 72 to 73 percent of women and men aged 60 to 79. Eight percent of adults have a diag- nosis of type 2 diabetes, another 3 percent are undiagnosed, and an additional 37 percent have prediabetes (Roger et al., 2011). Both high blood pressure and dia- betes (diagnosed and undiagnosed) increased between 1988-1994 and 2005-2008 at the same time that increases in obesity were observed (see below). And a grow- ing literature suggests various types of reductions in brain structural integrity (due to low blood flow to the brain) among both obese adolescents and adults (Gunstad et al., 2006; Maayan et al., 2011; Willeumier et al., 2011). In addition to these physical risks, obese adults face discrimination in employment settings and are sub- jected to inappropriate slurs and humor (Puhl and Heuer, 2001; Wear et al., 2006). Obese children and adolescents also suffer an array of obesity-related comor- bidities, ranging from sleep apnea, to type 2 diabetes, to hypertension, to liver disease, to orthopedic problems. These conditions over time may contribute to 35 Assessing the Current Situation

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shorter lifespans for obese children and adolescents. Poor health-related quality of life—physical, psychosocial, emotional, social, and school functioning—is 5.5 times greater in obese children and adolescents than in their normal-weight peers (Schwimmer et al., 2003). Childhood obesity is a major contributor to chronic ill- ness and accounts for increased use of medication and physician visits and associ- ated loss of school time (Van Cleave et al., 2010). Data suggest that obese children and adolescents miss more school days than their normal-weight peers regardless of age, ethnicity, sex, and school attended (Geier et al., 2007). And overweight or obese children and adolescents in every grade experience poorer academic out- comes than their normal-weight peers (Taras and Potts-Datema, 2005). Box 2-1 puts a human face on a day in the life of obese children and adoles- cents. A study of adolescents found that nearly 30 percent of girls and 25 per- cent of boys were teased by peers about their weight, and 29 percent of girls and 16 percent of boys were teased by family members (Eisenberg et al., 2003). Teasing about weight is associated with depression, low self-esteem and body satisfaction, and suicidal thoughts and attempts (Eisenberg et al., 2003). Obesity associates individuals with “different” negative stereotypes, which can encourage others to stigmatize them and discount their worth (Gray et al., 2011; Vander Wal and Mitchell, 2011; Williams et al., 2008). Economic and Societal Costs Economic and societal costs (see Table 2-2) are linked to the impact of the outcomes shown previously in Table 2-1 on health care costs and productivity. Many health care expenditures are both a direct and indirect result of the current epidemic of overweight and obesity (Wolf, 1998; Wolf and Colditz, 1998). Direct costs include preventive, diagnostic, and treatment services related to obesity; indi- rect costs are those associated with morbidity and mortality. The estimated annual cost of obesity-related illness based on data from the Medical Expenditure Panel Survey for 2000-2005 is $190 billion (in 2005 dollars), which represents 20.6 per- cent of annual health care spending in the United States (Cawley and Meyerhoefer, 2011). Childhood obesity alone is responsible for $14.1 billion in direct medical costs (Trasande and Chatterjee, 2009). Recent studies have modeled the economic benefits of reducing obesity preva- lence in the U.S. population. Obesity is the major modifiable risk factor for the development of diabetes and also increases the risk of developing hypertension. It is estimated that reducing the prevalence of diabetes and hypertension by 5 per- cent would save approximately $9 billion annually in the near term; with resulting Accelerating Progress in Obesity Prevention 36

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BOX 2-1 Childhood Days: Stories from Life* For many children and adolescents who are overweight or obese, childhood is a gauntlet of disappointment, depression, and disease. For example: • Mark and Kathy bring their 3-year-old child to a health clinic. Both parents are obese. They are adamant: “We do not want our child to go through what we did as children.” • Jonathan is 9 years old. He has sleep apnea, and must wear a heavy device on his face at night. This means he must take his “machine” for overnight visits with friends and relatives and try to explain why he is “different.” • Kelly is 10 years old. She is depressed and has suicidal thoughts. She reports, “The teasing starts on the bus to school, continues through the school day, and all the way home.” She has changed schools, but the teas- ing has only started again. • Tasha is an obese 15-year-old who loves soccer. She did well on the school team last year, but worries constantly that she won’t make the team next fall because of her weight. • Marco is 17 years old, with obesity and hypertension. Asked about his plans for the future, he responds with emotion, “I’ve always wanted to become a firefighter, but I know I won’t be able to because of my weight.” Similar stories about the challenges of living with obesity as an adult would remind us of the day-to-day burdens of living with hypertension, diabetes, or knee pain; the trips to doctors’ offices; and the costs and side effects of medi- cation. Too often, the immediate response to life stories such as these can be, “Why don’t they just lose weight?” Yet data show that contemporary culture, economics, and society pose many barriers to the types of healthy diets that prevent obesity from occurring and to the difficult tasks of losing excess weight and sustaining lower weight levels. *The individuals described in these illustrative examples are real pediatric patients; names have been changed for confidentiality. 37 Assessing the Current Situation

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TABLE 2-2 The Key Costs Identified from Research on the Economic Impact of Obesity Cost Category Subcategories Key Results, and Range of Estimates Direct medical Relative medical costs for overweight (vs. normal weight) spending Relative medical costs for obese (vs. normal weight) Annual direct costs of childhood obesity U.S.-wide annual cost of “excess” medical spending attributable to overweight/obesity Productivity Absenteeism Excess days of work lost due to obesity costs Relative risk ratio of having “high absenteeism” National costs of annual absenteeism from obesity Presenteeism National annual costs of presenteeism obesity Relative productivity loss due to obesity Disability Relative risk ratio of receiving disability income support Premature Years of life lost due to obesity mortality QALYs lost due to obesity Total National annual indirect costs of obesity Accelerating Progress in Obesity Prevention 38

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Relative Costs Total Costs Total Nondollar Amounts 10-20% highera,b 36-100% highera-d $14.3 billione,f $86-147 billion (total)c $640 billion (women 40-65 only)g 1.02-4.72 daysh-j 1.24-1.53 times higherj,k $3.38-6.38 billion, or $79-132 per obese personj,l $57,000 per employeel (1998 USD) $8 billionm (2002 USD) 1.5% higherj 5.64-6.92 percentage points highern 1-13 years per obese persono 2.93 million QALYs total in U.S. in 2004p $5 (1994 USD)-$66 billionm,q continued 39 Assessing the Current Situation

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TABLE 2-2 Continued Cost Category Subcategories Key Results, and Range of Estimates Transportation Fuel costs Annual excess jet fuel use attributable to obesity costs Annual excess fuel use by noncommercial passenger highway vehicles Additional fuel required in noncommercial passenger highway sector per lb of average passenger weight increase Environmental OECD-wide CO2 emissions from transportation per 5 kg costs average weight per person Human capital Highest grade completed accumulation costs Days absent from school NOTES: OECD = Organisation for Economic Co-operation and Development; QALY = quality-adjusted life-years. aThompson et al., 1999; bThompson et al., 2001; cFinkelstein et al., 2009; dThorpe et al., 2004; eCawley, 2010; fTrasande and Chatterjee, 2009; gGorsky et al., 1996; hPronk et al., 1999; iTsai et al., 2008; jTrogdon et al., 2008; kSerxner et al., 2001; lDurden et al., 2008; mRicci and Chee, 2005; nBurkhauser and Cawley, 2004; oFontaine et al., 2003; pGroessl et al., 2004; qThompson et al., 1998; rDannenberg et al., 2004; sJacobson and King, 2009; tJacobson and McLay, 2006; uMichaelowa and Dransfield, 2008; vGortmaker et al., 1993; wKaestner et al., 2009; xGeier et al., 2007. SOURCE: Reprinted with permission from Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, volume 3, Hammond, R. A., and R. Levine, The economic impact of obesity in the United States, pages 285-295, Copyright 2010, with permission from Dove Medical Press Ltd. reductions in comorbidities and related conditions, savings could rise to approxi- mately $24.7 billion annually in the medium term (Ormond et al., 2011). Many of these obesity-related health care costs are paid with public dollars. For example, it is estimated that total Medicare and Medicaid spending would be 8.5 percent and 11.8 percent lower, respectively, in the absence of obesity (Finklestein et al., 2009). Moreover, these health care costs are expected to rise significantly, since today’s increased rates of childhood obesity predict further increases in adult obesity and concomitant increases in hypertension, stroke, dys- lipidemia, cancers (endometrial, breast, and colon), osteoarthritis, sleep apnea, liver and gall bladder disease, respiratory problems, and type 2 diabetes. Accelerating Progress in Obesity Prevention 40

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Relative Costs Total Costs Total Nondollar Amounts 350 million gallonsr $742 million (2010 USD) 938 million-1 billion gallonss,t $2.53-2.7 billion (2010 USD) 39 million gallonst $105 million per lb (2010 USD) 10 million tonsu 0.1-0.3 fewer grades completedv,w 1.2-2.1 more days absent from schoolx The U.S. economy struggles today to cope with health care spending; this struggle will grow progressively more difficult as today’s obese children mature. Beyond growing medical costs attributed to obesity, the nation will incur higher costs for disability and unemployment benefits. Businesses currently suffer because of obesity-related job absenteeism ($4.3 billion annually) (Cawley et al., 2007); these costs also will continue to grow. Societal expenses add to the effects of the reduced standard of living and quality of life experienced by affected individuals and their families. Obesity has economic implications even in the absence of health detriments. For example, employers are less likely to hire obese than normal-weight indi- 41 Assessing the Current Situation

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viduals with the same qualifications; when hired, obese individuals are likely to report being paid lower wages and suffering other additional discrimination (Giel et al., 2010; Han et al., 2011). The result is underutilization of available skills at a cost to both society and individuals. The economic repercussions of discrimina- tion affect families as well. Because decreased fitness in obese people may lead to increased health problems (IOM, 2010a) and reduced household income (Cawley, 2004; Puhl and Brownell, 2001), the additional struggles due to loss of health and income may in turn lead to an erosion of family cohesiveness and strength. Rising rates of obesity also affect national security; U.S. military leaders have recently described the role of obesity in reducing the pool of potential recruits to the armed services (Christeson et al., 2010). These human and societal consequences clearly justify action. Agreement is now widespread that priority should be given to population-oriented preventive approaches that can curb the development or exacerbation of excess weight gain and obesity rather than to individual case finding and treatment. This applies not only to children and adolescents, so that lifelong prevention can begin as early as possible, but also to adults, among whom the health burdens of obesity are greatest. Even without further growth in current levels of overweight and obesity, future burdens of obesity-related illness, poor health, and quality of life will con- tinue to grow significantly, as will the financial costs of health care for families, employers, health care institutions, and the public. OBESITY PREVALENCE AND TRENDS The United States continues to experience an epidemic of overweight and obesity that compels timely and effective action. Although obesity is not a new problem, the percentage of people affected was relatively stable until the 1980s, when it began to rise (NCHS, 2010). By adulthood, the prevalence of obesity is approximately twice that observed during childhood, reflecting both the track- ing of child and adolescent obesity into adult years and the new onset of obesity as many adults experience gradual, progressive weight gain in their 20s, 30s, and 40s. Currently, a majority of U.S. adults and a substantial proportion of children and adolescents have weight levels in the overweight or obese range. Definitions of Overweight and Obesity Definitions of overweight and obesity for children, adolescents, and adults are provided in Box 2-2. According to these definitions, two-thirds of adult Accelerating Progress in Obesity Prevention 42

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BOX 2-2 Definitions of Overweight and Obese Adults Overweight is defined as a body mass index (BMI) (a ratio of weight in kilograms to the square of height in meters) of 25-29.9. Adults with a BMI of 30 or greater are considered obese. Among those who are obese, the increas- ing health risks at higher levels of weight are sometimes indicated by further classification into grades of increasing severity: grade 1 obesity is defined as a BMI of 30 to 34.9, grade 2 is a BMI of 35.0 to 39.9, and grade 3 is a BMI of 40 or greater. Children and Adolescents Overweight and obesity are defined by cutoffs on sex- and age-specific Centers for Disease Control and Prevention (CDC) BMI reference curves to account for growth and maturation: overweight, including obesity, is defined as a BMI at or above the 85th percentile; obesity is defined as a BMI at or above the 95th percentile. Americans are overweight or obese, and the proportion who are obese has more than doubled since 1976-1980, when it was 15 percent (NCHS, 2011). Even more stunning is the parallel phenomenon in adolescents aged 12 to 19, among whom the 5 percent obesity prevalence of 1976-1980 has now more than tripled (NCHS, 2011). Figure 2-1 shows the consistent proportion of men and women in the over- weight range (reflecting fewer people in the healthy weight range) but continu- ing trends of increasing obesity during the most recent two decades. In men, the prevalence of obesity increased by 13 percentage points from 1988 to 2008—from 19 percent to 32 percent—and doubled (from 5 percent to 11 percent) within the grade 2 obesity category. In women, obesity prevalence increased by 10 percentage points during the same period—from 25 percent to 35 percent—with a 7 percent- age point increase in the grade 2 obesity category (from 11 percent to 18 percent) (NCHS, 2011). Figure 2-2 shows the steady gradient of increasing obesity preva- 43 Assessing the Current Situation

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vation does not apply evenly across all population subgroups and also may not be sustained or lead to a lessening of the current high rate. Contributors to these potential precursors of success must be identified and translated into approaches for permanent change. Of greatest importance in this respect is that early signs of success, even if real, not be misunderstood to be success. Success will occur once population weight levels are in a healthy range. All of the adverse consequences— human and economic—of the obesity epidemic described here are entrenched and will continue to increase as children and adolescents on a course to become obese mature. The next chapter of this report describes specific goals and strategies for addressing obesity and examines practical and policy considerations relevant to their implementation. REFERENCES ACHI (Arkansas Center for Health Improvement). 2011. Combating childhood obesity. http://www.achi.net/ChildObDocs/2004%20Statewide%20BMI%20Report.pdf (accessed October 14, 2011). Agron, P., V. Berends, K. Ellis, and M. Gonzalez. 2010. School wellness policies: Perceptions, barriers, and needs among school leaders and wellness advocates. Journal of School Health 80(11):527-535. Alliance for a Healthier Generation. 2005. Clinton Foundation and American Heart Association form alliance to create a healthier generation. http:// www.healthiergeneration.org/uploadedFiles/For_Media/afhg_nr_alliance_ formation_5-3-05.pdf (accessed January 4, 2012). American Heart Association. 2010. Understanding childhood obesity. http:// www.heart.org/idc/groups/heart-public/@wcm/@fc/documents/downloadable/ ucm_304175.pdf (accessed December 29, 2011). Bell, J., and L. Dorfman. 2008. Introducing the healthy eating active living conver- gence partnership. http://www.convergencepartnership.org/atf/cf/%7B245A9B44- 6DED-4ABD-A392-AE583809E350%7D/CP_Introduction_printed.pdf (accessed January 4, 2012). Better Business Bureau. 2006. New food, beverage initiative to focus kids’ ads on healthy choices; revised guidelines strengthen CARU’s guidance to food advertisers. http://www.bbb.org/us/article/new-food-beverage-initiative-to-focus-kids-ads-on- healthy-choices-revised-guidelines-strengthen-carus-guidance-to-food-advertisers-672 (accessed January 4, 2012). Bleich, S. N., Y. C. Wang, Y. Wang, and S. L. Gortmaker. 2009. Increasing consump- tion of sugar-sweetened beverages among US adults: 1988-1994 to 1999-2004. The American Journal of Clinical Nutrition 89(1):372. Accelerating Progress in Obesity Prevention 68

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