Population Health: The Big Picture
Preventing Childhood Obesity
The nation must act now, or it will watch its children grow into adults with excessive levels of diabetes, heart disease, cancer, and other weight-related ailments.
After improving dramatically during the past century, the health of children and youth in the United States now faces a dangerous setback: an epidemic of obesity. It is occurring in boys and girls in every state, in younger children and adolescents, across all socioeconomic strata, and among all ethnic groups. Traditionally, most people have considered weight to be a personal statistic, of concern only to themselves or, on occasion, to their physicians. Both science and statistics, however, argue that this view must change. As researchers learn ever more about the health risks of obesity, the rise in the prevalence of obesity in children—and in adults as well—is increasingly becoming a major concern to society at large and hence a public health problem demanding national attention.
Since the 1970s, when the epidemic began to take hold, the prevalence of obesity has nearly tripled for children aged 6 to 11 years (from 4 percent to 15.3 percent), and it has more than doubled for youth aged 12 to 19 years (from 6.1 percent to 15.5 percent) and for children aged 2 to 5 years (from 5 percent to 10.4 percent). Although no demographic group is untouched, some subgroups have been affected more than others. Children in certain minority ethnic populations (including African Americans, American Indians, and Hispanics), children in low-income families, and children in the country’s southern region tend to have higher rates of obesity than the rest of the population.
Today, more than 9 million children over age 6 are considered obese, which means that they face serious immediate and long-term health risks. They are at increased risk as they grow older of a number of diseases, including type 2 diabetes, cardiovascular disease, hypertension, osteoarthritis, and cancer. By being obese in a society that stigmatizes this condition, they also may develop severe psychosocial burdens, such as shame, self-blame, and low self-esteem, that may impair academic and social functioning and carry into adulthood.
Pared to its core, the solution is simple: Preventing obesity will require ensuring that children maintain a proper energy balance. This means that each child will consume enough of the right kinds of food and beverages and get enough physical activity to maintain a healthy weight while supporting normal growth and development and protecting overall health. Although this “energy intake = energy expenditure” equation may appear fairly simple, in reality it is extraordinarily complex. At work are a multitude of factors—genetic, biological, psychological, sociocultural, and environmental—acting independently and in concert.
Thus, combating the epidemic will be challenging. But there is precedent for success in other public health endeavors of comparable complexity and scope. Major gains have been made, for example, in reducing tobacco use, including preventing youth from smoking, and in improving automobile safety, including promoting the use of car seats and seatbelts to protect young passengers. Some lessons can be drawn from these efforts, past and current, and many new ideas and approaches will be needed to meet conditions specific to the task at hand. One overarching principle is clear: Preventing childhood obesity on a national scale will require a comprehensive approach that is based soundly on science and involves government, industry, communities, schools, and families.
Such an approach is detailed in Preventing Childhood Obesity: Health in the Balance, issued by the Institute of Medicine in September 2004. The report examines the various factors that promote childhood obesity, identifies promising methods for prevention, describes continuing research needs, and assigns responsibilities for action across a broad sweep of society. Its recommendations, when implemented together, will help keep the vast majority of the nation’s children physically active and healthy. Some highlights of the report are offered in the following sections.
Strengthening political muscle
As many other public health programs have demonstrated, catalyzing national action to prevent childhood obesity will require the full commitment of government at all levels. The federal government should take the lead by declaring this a top public health priority and dedicating sufficient funding and resources to support policies and programs that are commensurate to the scale of the problem. The government also should ensure that prevention efforts are coordinated across all departments and agencies, as well as with state and local governments and various segments of the private sector.
Toward this end, the president should request the Department of Health and Human Services (DHHS) to convene a high-level task force (including the secretaries or senior officials of all departments and agencies whose work relates in any way to childhood obesity) to be responsible for establishing priorities and promoting effective collaborations. In order to foster full and free communication, the task force should meet regularly with local and state officials; representatives from nongovernmental organizations, including civic groups, youth groups, advocacy groups, and foundations; and representatives from industry.
In addition to providing broad leadership, the federal government should take a variety of specific steps. For example, funding should be increased for surveillance and monitoring systems that gather information needed for tracking the spread of childhood obesity and for designing, conducting, and evaluating prevention programs. In particular, the National Health and Nutrition Examination Survey, which for years has been used to monitor the population through home interviews and health examinations, should be strengthened, with more attention being paid to collecting and analyzing data that will inform prevention efforts. Special efforts should be made through this and other surveillance systems to better identify and monitor the populations most at risk of childhood obesity, as well as the social, behavioral, and environmental factors contributing to that elevated risk.
Among other steps, the government should increase support for public and private programs that educate children, youth, and their families about the importance of good nutrition and regular physical activity. Similarly, federal nutrition assistance programs, including the Department of Agriculture’s (USDA’s) Food Stamp Program and the Special Supplemental Nutrition Program for Women, Infants, and Children, should be expanded to include obesity prevention as an explicit goal. Congress should request independent assessments of these assistance programs to ensure that each provides adequate access to healthful dietary choices for the populations served.
In addition, pilot studies should be expanded within these programs to identify new ways to promote a healthful diet and regular physical activity behaviors. Ideas include using special vouchers or coupons for purchasing fruits, vegetables, and whole-grain baked goods; sponsoring discount promotions; and making it possible to use electronic benefit transfer cards at farmers’ markets or community-supported agricultural markets. Test programs that prove successful should be scaled up as quickly as possible.
Congress also should call for an independent assessment of federal agricultural policies, including subsidies and commodity programs that may affect the types and quantities of foods available to children through food assistance programs. For example, concern has been expressed about whether the increasing amounts of caloric sweeteners (primarily derived from sugarcane, beets, and corn) that people are consuming are contributing to the obesity epidemic, and whether subsidies for these crops are promoting the production of inexpensive caloric sweeteners. These possible relationships warrant further investigation. If problems are confirmed in this or other cases, then the government should revise its policies and programs to promote a U.S. food system that supports energy balance at a healthy weight.
For their part, state and local governments should join in making the prevention of childhood obesity a priority by providing the leadership—and resources—needed to launch and evaluate a slate of programs and activities that promote physical activity and healthful eating in communities, neighborhoods, and schools. One important step, for example, will be for governments to strengthen their public health agencies. As the front line of the public health system, these agencies are ideally positioned to assess the childhood obesity epidemic; to identify local conditions that are fueling it; and then to develop, implement, and evaluate prevention programs. In order to perform most effectively, however, many agencies will need restructuring to make them better able to work collaboratively with diverse community partners. Such partners can include schools, child-care centers, nutrition services, civic and ethnic organizations, faith-based groups, businesses, and community planning boards.
Harnessing the market
Children, youth, and their families are surrounded by a commercial environment that strongly influences their purchasing and consumption behaviors as well as the choices they make in how to spend their leisure time. Thus, a variety of industries (including the food, beverage, restaurant, entertainment, leisure, and recreation industries) must share responsibility for preventing childhood obesity. Government can help strengthen industry efforts by providing technical assistance, research expertise, and, as necessary, targeted support and regulatory guidance.
As a general goal, industries should develop and promote products, opportunities, and information that will encourage healthful eating behaviors and regular physical activity. In order to improve the “expenditure” side of the energy balance equation, the leisure, entertainment, and recreation industries should step up efforts to promote active leisure-time pursuits and to develop new products and markets. Such efforts can help to reverse the recent trend that has seen people spending more time in passive sedentary pursuits and less in active leisure activities. Some companies already are setting the pace, apparently convinced that fostering physical activity will help to create significant markets for their products. For example, Nike, a manufacturer of athletic apparel, provides funding to build or refurbish sports courts and other public athletic facilities nationwide and supports physical education classes in elementary schools, among other projects. More projects of this kind are needed.
In order to improve the “intake” side of the equation, the food and beverage industries should put more effort into developing products that have low energy densities and are appealing to consumers. Foods with low energy densities, such as fruits and vegetables, promote satiety and reduce total caloric intake, but they sometimes meet resistance in the marketplace, especially among people who have become used to foods of higher energy densities. Manufacturers, perhaps motivated by some form of government incentive, should continue to push for healthful new products that are more appealing to a range of people. They also should speed up modifying existing products—for example, by replacing fat with protein, fruit or vegetable puree, fiber, or even air—to reduce energy density but maintain palatability without substantially reducing product size. As another line of attack, manufacturers should develop new forms of product packaging that would help consumers choose smaller, standard serving sizes without reducing product profitability.
Full-service and fast-food restaurants have important roles to play as well, given that people are consuming an increasing share of their meals and snacks outside of the home. Among a range of steps they should take, restaurants should continue to expand their healthier meal options by offering more fruits, vegetables, low-fat milk, and calorie-free beverages, and they should mount information campaigns to provide consumers at the point of purchase with easily understandable nutrition information about all of their products. The industry also should explore price incentives that encourage consumers to order smaller meal portions.
Industry also should make better use of nutrition labeling, which has been mandatory since 1990, to provide parents and youth with clear and useful information that will enable them to compare products and make informed food choices. Here, government can help. The Food and Drug Administration (FDA) should modify the nutrition facts panels—the familiar information charts printed on food products—to more prominently display the calorie content of a standardized serving size and the “percent daily value” (the percent of nutrients contained in a single serving, based on a 2,000-calorie-per-day diet) of key nutrients. But in many instances, people consume all at once quantities that are much larger than a standardized serving size. This is often the case for vending-machine items, single-serving snack foods, and ready-to-eat foods purchased at convenience stores. Such consumers are left on their own to calculate the nutritional content of their purchases. To help them out, the FDA should mandate that manufacturers prominently add the total calorie content to the nutrition facts panels on products typically consumed at one eating occasion.
Of course, any consideration of industry’s impact on the choices that families and children make about eating and engaging in physical activities cannot overlook the role of advertising. Together, these industries are the second-largest advertising group in the U.S. economy, after the automotive industry, and young people are a major target. Current evidence suggests that the quantity and nature of advertisements to which children are exposed daily, reinforced through multiple media channels, appear to contribute to choices that can adversely affect their energy balance. Thus, industry has an important responsibility and opportunity to help foster healthier choices.
As a catalyst, DHHS should convene a national conference, bringing together representatives from industry, public health organizations, and consumer advocacy groups, to develop guidelines for the advertising and marketing of foods, beverages, and sedentary entertainment directed at children and youth. The guidelines would cover advertising content, promotion, and placement. They should pay particular attention to protecting children under the age of 8, as they are especially susceptible to the persuasive intent of advertising. Industry would then be responsible, on a voluntary basis, for implementing the guidelines. However, the Federal Trade Commission should be given the authority and resources to monitor compliance and to propose more stringent regulations if industry fails in its actions.
Building healthy communities
Many factors in the community setting affect the overall health and fitness of children and youth. Writ large, a community can be a town, city, or other type of geographic entity where people share common institutions and, usually, a local government. In turn, each of these communities contains many interdependent smaller networks of residential communities, faith-based communities, work communities, and social communities. Thus, there is a host of leverage points at which communities can help foster social norms that promote attitudes and behaviors that will help their young members maintain a healthy weight.
In one approach, community groups—or, ideally, community coalitions—should expand current programs and establish new ones that widen children’s opportunities to be physically active and maintain a balanced diet. Many youth organizations, such as Boys and Girls Clubs, Girl Scouts, Boy Scouts, and 4H, already have a number of programs under way that illustrate the gains possible. In one Girl Scout program, for example, girls who participated with their troops in nutrition classes, which included tasting sessions and sending foods home, were found to consume more fruits and vegetables on a regular basis. Youth groups also can help get more kids involved in physical activity by pursuing innovative approaches that reach beyond traditional competitive sports. These sports are not of interest to everyone, so it will be important for communities to expand their range of offerings to include noncompetitive team and individual sports as well as other types of physical activities, such as dance and martial arts. To ensure equal access to physical activity programs, communities should help families overcome potential obstacles by providing transportation, paying fees, or providing special equipment.
Communities also should take a hard look at their built environments and expand the opportunities for children to be physically active outside, especially in their neighborhoods. Creating places to walk, bike, and play will require not only providing adequate space but also reducing risks from traffic or crime. Local governments, private developers, and community groups should work collaboratively to develop more parks, playgrounds, recreational facilities, sidewalks, and bike paths. It will be especially important for communities to ensure that children and youth have safe walking and bicycling routes between their homes and schools and that they are encouraged to use them. Making such improvements often will require local governments to revise their development plans, zoning and subdivision ordinances, and other planning practices, and to prioritize the projects in their capital improvement programs.
Similarly, communities should expand efforts to provide their residents with access to healthful foods within walking distance, particularly in low-income and underserved neighborhoods. Some promising approaches include offering government financial incentives, such as grants, loans, and tax benefits, to stimulate the development of neighborhood grocery stores; developing community and school gardens; establishing farmers’ markets; and supporting farm-to-school and farm-to-cafeteria programs.
It is within local communities, of course, where most health care is provided, and health care professionals have an influential role to play in preventing childhood obesity. As advisors to children and their parents, they have the access and influence to make key suggestions and recommendations on dietary intake and physical activity throughout children’s lives. They also have the authority to elevate concern about childhood obesity and advocate preventive efforts. By conducting workshops at schools, testifying before legislative bodies, working in local organizations, or speaking out in any number of other ways, health care professionals can press for changes within their communities that support and facilitate healthful eating and physical activity.
In their everyday practices, health care professionals (pediatricians, family physicians, nurses, and other clinicians) should routinely measure the height and weight of their patients and track their body mass indices (BMIs). They then should carefully communicate the results to the children themselves, in an age-appropriate manner, and to their parents or other caregivers; provide information that the families need to make informed decisions about nutrition and physical activity; and explain the risks associated with childhood overweight and obesity.
In order to make sure that health care professionals are well prepared to provide quality services, medical and nursing schools should incorporate training with regard to nutrition, physical activity, and counseling on obesity prevention into their curricula. Training should happen at all levels, from preclinical science through the clinical training years and into postgraduate training programs and continuing medical education programs for practicing clinicians. Health care professional organizations also should make obesity prevention a high priority. Actions they should take to back up their commitment include creating and disseminating evidence-based guidance and other materials on obesity prevention and establishing programs to encourage their members to be role models for proper nutrition and physical activity. In addition, accrediting organizations should add obesity prevention skills, such as tracking BMIs and providing needed counseling, to the measures they routinely assess.
Health insurers and group health plans can make valuable contributions as well. Indeed, the high economic costs of obesity provide them with major incentives to encourage healthful lifestyles. Creative options may include providing member families with incentives to participate in regular physical activity, perhaps by offering discounted fees for joining health clubs or participating in other exercise programs. It will be particularly important for insurers and health plans to consider incentives that are useful to high-risk populations, who often live in areas where easy access to recreational facilities is lacking or costs are prohibitive.
Lessons for schools
Given that schools are one of the primary locations for reaching children and youth, it is critically important that the total school environment—cafeteria, playground, classrooms, and gymnasium—be structured to promote healthful eating and physical activity. Needs abound.
Schools, school districts, and state educational agencies should ensure that all meals served in schools comply with the DHHS and USDA’s Dietary Guidelines for Americans, which recommend that no more than 30 percent of an individual’s calories come from fat and less than 10 percent from saturated fat. Further, USDA should conduct pilot studies to evaluate the costs and benefits of providing full funding for breakfasts, lunches, and snacks in schools with a large percentage of children at high risk of obesity.
Increasingly, students are getting more of their foods and beverages outside of traditional meal programs. Many of these “competitive” foods, which are sold in cafeterias, vending machines, school stores, and fundraisers, or provided as snacks in classrooms and after-school programs, are high in calories and low in nutritional value. Current federal standards for such items are minimal. USDA, with independent scientific advice, should establish nutritional standards for all food and beverage items served or sold in schools. In turn, state education agencies and local school boards should adopt these standards or develop stricter standards for their schools. Enforcing such schoolwide standards not only will promote student health but help establish a broader social norm for healthful eating behaviors.
Schools also need to reinvigorate their commitments to providing students with opportunities to be physically active. Many schools have cut physical education classes or shrunk recess times, often as a result of budget cuts or pressures to increase academic offerings. Students are paying the price. Schools should ensure that all children and youth participate in at least 30 minutes of moderate to vigorous physical activity during the school day. This goal is equally important for young children in child development centers and other preschool and child-care settings. Congress, state legislatures and education agencies, local governments, school boards, and parents should hold schools responsible for providing students with recommended amounts of physical activity. Concurrently, they should ensure that schools have the resources needed to do the job properly.
Among the actions that schools can take to get students more active, they should provide physical education classes of 30 minutes to an hour on a daily basis, and they should examine ways to incorporate into these classes innovative activities that will appeal to the broad range of student interests. Elementary schools, middle schools, and child development centers should provide equal amounts of recess. Schools also should offer a broad array of after-class activity programs, such as intramural and interscholastic sports, clubs, and lessons that will interest all students. In addition, schools should be encouraged to extend the school day as a means of providing expanded instructional and extracurricular physical activity programs.
Schools offer many other opportunities as well to help students avoid developing weight problems. They should ensure that nutrition, physical activity, and wellness concepts are taught throughout the curriculum from kindergarten through high school, and they should incorporate into health classes evidence-based programs that teach behavioral skills that students can use to make better choices about foods and physical activity. Federal and state departments of education, along with education and health professional organizations, can support this effort. These organizations should develop, implement, and evaluate pilot programs that use innovative approaches for teaching about wellness, nutrition, physical activity, and making choices that promote wellness, as well as for recruiting and training teachers to meet expanding needs.
Health clinics and other school-based health services also can play a prominent role in prevention efforts. In particular, they should measure yearly each student’s weight, height, and gender- and age-specific BMI percentile and make this information available to parents and to the student (when age-appropriate). It will be important that such data be collected and reported validly and appropriately, with the utmost attention to privacy concerns. The Centers for Disease Control and Prevention can help in this regard by developing guidelines that schools can follow in gathering information and communicating the results.
Parents, defined broadly to include primary caregivers, have a profound influence on their children by fostering values and attitudes, by rewarding or reinforcing specific behaviors, and by serving as role models. The family is a logical target for interventions designed to prevent childhood obesity. This focus is made even more important by changes in society in recent decades that are adding pressures on parents and children that can adversely affect choices about food and physical activity. For example, with the frequent need for both parents to work long hours, it has become more difficult for many parents to play with or monitor their children and to prepare home-cooked meals for them.
Along with challenges, however, come opportunities and responsibilities. In order to promote healthful food choices, parents should make available in the home foods such as fruits and vegetables that are nutritious and have low energy densities and should limit purchases of items characterized by high calorie content and low nutritional value. Parents also should assist and educate their children in making good decisions regarding types of foods and beverages to consume, how often, and in what portion size. Similarly, parents should encourage their children to play outdoors and to participate in other forms of regular physical activity. By the same token, they should discourage their children from participating excessively in sedentary pursuits by, for example, limiting television viewing and other recreational screen time, such as playing video games, to less than two hours per day.
Among other actions, parents should consider the weight of their children to be a critically important indicator of health. Just as vaccination schedules require parental intervention during childhood, parents should be discussing the prevention of obesity with their health care providers to make sure that their child is on a healthy growth track. In practice, parents should have a trained health professional regularly (at least once a year) measure their child’s height and weight in order to track his or her BMI percentile. School health programs may be of critical help here, because many families lack insurance for preventive health services and cannot afford regular health screening. Underlying all of these efforts, parents should try their best to serve as positive role models by practicing what they are preaching.
The epidemic of childhood obesity, long overlooked, now looms as a major threat to the nation’s health. Many stakeholders, public and private, are starting to take action to help slow and ultimately reverse its course. Preventing Childhood Obesity reviews progress and outlines a way to move forward in what must be viewed as a collective responsibility and an energetic and sustained effort. Some of the steps can be implemented immediately and will cost little. Others will cost more and will require a longer time for implementation and to see the benefits of the investment. Some actions will prove useful, either quickly or over the longer term, whereas others are likely to prove unsuccessful.
But the nation cannot wait to design a “perfect” prevention program in which every intervention has been scientifically tested ahead of time to guarantee success. Wide-ranging intervention programs are needed now, based on the best available evidence. At the same time, research must continue to refine efforts. Briefly, research is needed to evaluate the effectiveness, including the cost-effectiveness, of prevention programs; to better understand the fundamental factors involved in changing personal dietary behaviors, physical activity levels, and sedentary behaviors; and to explore the range of population-level factors that drive changes in the health of communities and other large groups of people.
Thus, the path ahead will involve surveillance, trial, measurement, error, success, alteration, and dissemination of the knowledge and practices that prove successful. The key is to move ahead, starting immediately, on every front. As institutions, organizations, and individuals across the nation begin to make changes, social norms are also likely to change, so that obesity in children and youth will be acknowledged as an important and preventable health outcome, and healthful eating and regular physical activity will be the accepted and encouraged standard. Given that at stake is the health of today’s children and youth, as well as the health of future generations, the nation must proceed with all due urgency and vigor.
Jeffrey P. Koplan, vice president for academic health affairs at the Woodruff Health Sciences Center at Emory University in Atlanta, was chair of the committee that produced the Institute of Medicine report Preventing Childhood Obesity: Health in the Balance. Catharyn T. Liverman was study director, and Vivica I. Kraak was a senior program officer for the report.