Lynn Parker, Institute of MedicineWeight of the StateVirginia Health FoundationApril 11, 2013

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Where are we now?

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Health Consequences

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Health ConsequencesOBESITY CAN CAUSE OTHER HEALTH PROBLEMSCardiovascular DiseaseType 2 DiabetesHigh Blood PressureSleep ApneaDepression

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Health Consequences

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Scope and Societal Costs

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HBO/IOMs The Weight of the NationHBO/IOM/CDC/NIH/Michael & Susan Dell Foundation/Kaiser Permanente

Documentaries (4) for adult audienceShort documentaries (12) on specific topics in obesity preventionTrade publication for general audiences (The Weight of the Nation)Website (http://theweightofthenation.hbo.com/)Social media (Facebook, Twitter, Youtube, and GetGlue)Screening kits with discussion guidesMarketing efforts, including reaching families with childrenDocumentaries (3) for children and familiesWritten materials for school-age children and teachers (Scholastic, Inc.)

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Committee on Accelerating Progress in Obesity Prevention

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Committee MembershipDaniel Glickman (chair), The Aspen Institute and Bipartisan Policy CenterM.R.C. Greenwood (vice chair), University of Hawaii SystemWilliam Purcell (vice chair), Jones Hawkins & FarmerDavid Britt, retired Sesame WorkshopJamie Chriqui, University of Illinois, ChicagoPatricia Crawford, University of CaliforniaChristina Economos, Tufts University

Sandra Hassink, A.I. duPont Hospital for ChildrenAnthony Iton, The California EndowmentSteven Kelder, University of TexasHarold (Bill) Kohl, University of TexasShiriki Kumanyika, University of PennsylvaniaPhilip Marineau, LNK PartnersVicky Rideout, VJR ConsultingEduardo Sanchez, Blue Cross and Blue Shield of TexasEllen Wartella, Northwestern University

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Review of Prior Recommendations~ 800 obesity prevention-related recommendations!

Comprehensive review reflecting Institute of Medicine and National Research Council Childhood Obesity Action NetworkHealthy Eating Activity Living Convergence PartnershipUS Department of Health and Human Services (CDC, Community Preventive Services Task Force)Keystone ForumNational Governors AssociationNational Association of County and City Health OfficialsNational Physical Activity Plan Robert Wood Johnson FoundationTrust for Americas HealthUSDAWhite House

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GoalsIntegrate Physical Activity Every Day in Every WayMake Healthy Foods Available EverywhereMarket What Matters for a Healthy LifeActivate Employers and Health Care ProfessionalsStrengthen Schools as the Heart of Health

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Physical Activity: Recommendation 1Communities, transportation officials, community planners, health professionals, and governments should make promotion of physical activity a priority by substantially increasing access to places and opportunities for such activity.

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Physical Activity StrategiesStrategy 1-1: Enhance the physical and built environment.

Strategy 1-2: Provide and support community programs designed to increase physical activity.

Strategy 1-3: Adopt physical activity requirements for licensed child care providers.

Strategy 1-4: Provide support for the science and practice of physical activity.

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Food and Beverage Environments:Recommendation 2Governments and decision makers in the business community/private sector should make a concerted effort to reduce unhealthy food and beverage options and substantially increase healthier food and beverage options at affordable, competitive prices.

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Food and Beverage StrategiesStrategy 2-1: Adopt policies and implement practices to reduce overconsumption of sugar-sweetened beverages. Strategy 2-2: Increase the availability of lower-calorie and healthier food and beverage options for children in restaurants. Strategy 2-3: Use strong nutritional standards for all foods and beverages sold or provided through the government, and ensure that these healthy options are available in all places frequented by the public.Strategy 2-4: Use financial incentives and zoning strategies to improve local food environments, linking incentives to stores that commit to healthy food promotion.Strategy 2-5: Examine the effects of U.S. agriculture policies on diets and obesity.

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Message Environment: Recommendation 3Industry, educators, and governments should act quickly, aggressively, and in a sustained manner on many levels to transform the environment that surrounds Americans with messages about physical activity, food, and nutrition.

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Messaging StrategiesStrategy 3-1: Develop and support a sustained, targeted physical activity and nutrition social marketing program. Strategy 3-2: Implement common standards for marketing foods and beverages to children and adolescents. Strategy 3-3: Ensure consistent nutrition labeling for the front of packages, retail store shelves, and menus and menu boards that encourages healthier food choices. Strategy 3-4: Adopt consistent nutrition education policies for federal programs with nutrition education components.

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Health Care, Insurers, and Work Sites:Recommendation 4Health care and health service providers, employers, and insurers should increase the support structure for achieving better population health and obesity prevention.

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Health Care, Insurers, and Worksites StrategiesStrategy 4-1: Provide standardized care and advocate for healthy community environments. Strategy 4-2: Ensure coverage of, access to, and incentives for routine obesity prevention, screening, diagnosis, and treatment. Strategy 4-3: Encourage active living and healthy eating at work. Strategy 4-4: Encourage healthy weight gain during pregnancy and breastfeeding, and promote breastfeeding-friendly environments.

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Schools: Recommendation 5Federal, state, and local government and education authorities, with support from parents, teachers, and the business community and the private sector, should make schools a focal point for obesity prevention.

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School StrategiesStrategy 5-1: Require quality physical education and opportunities for physical activity in schools. Strategy 5-2: Ensure strong nutritional standards for all foods and beverages sold or provided through schools. Strategy 5-3: Ensure food literacy, including skill development, in schools.

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Five Interacting Areas

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Meeting the Challenge of Achieving Equity

Transform inequitable environmentsFood and BeveragePhysical ActivityMessage

Target Critical SettingsSchoolWorksites

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Engagement Leadership and ResponsibilityAssessment

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The Robert Wood Johnson Foundation Michael & Susan Dell Foundation (Measuring Progress in Obesity Prevention: Workshop Report).

Study Staff: Lynn Parker, Leslie Sim, Heather Cook, Emily Ann Miller, Heather Breiner, Elena Ovaitt, and Matt Spear

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To read more about the project and download the full reports, visit: http://www.iom.edu/acceleratingobesityprevention

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For more information on obesity, visit:http://www.iom.edu/obesity Thank you!

Over the past 5 years, the Virginia Department of Education, Virginia Department of health, and Virginia Foundation for Healthy Youth have combined efforts with the goal to collect baseline data on the prevalence of childhood overweight and obesity in Virginia and to measure trends and progress in reducing childhood obesity overtime.

This research provides current estimates of overweight and obesity among youth in Virginia as well as information concerning eating habits and physical activity. The survey results provide us with important information that will help to inform the development and refinement of programs and policies throughout the Commonwealth. We will continue to analyze this data carefully in the coming months.

**5/4/2012Causes of the high rates of obesity can be traced to trends in environmental influences on physical activity and food intake:

Calorie consumption has gone upPortion sizes have increasedSugar-sweetened beverage consumption is too high

At the same time:

Physical activity levels have decreased among kids and adults Sedentary activity has increased, due in part to the many hours we now spend in front of screens

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What does our current situation mean? That 1 out of every 3 children AND 2 out of every 3 adults are overweight or obese.

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And obesity is associated with a number of health consequences, including: cardiovascular disease, type 2 diabetes, high blood pressure, sleep apnea, depression, among many other physical, psychosocial (stigma, low self-esteem), and functional (unemployment, reduced productivity) problems.

*5/4/2012Regarding Type 2 Diabetes:An estimated 11% of adults have type 2 diabetes, but more alarming is that 37% of adults are considered pre-diabeticEven more worrisome, it has been estimated that 1/3 of all children born today will develop type 2 diabetes in their lifetime (and of Latino and black children!).

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These health consequences in turn:Cost the country an estimated $190.2 billion in obesity-related illnessesthat represents 20% of all health care spending.An estimated loss of $4.3 billion dollars to businesses because of obesity-related absenteeism.

*5/4/2012The urgency of the situation requires the speeding up of progress in arresting this obesity epidemic. There have been numerous promising interventions recommended and implemented in this country over the past decade to combat this problem, but our progress has been slow.

THAT IS WHY this committee was brought together to help guide direction of action over the next decade by reviewing past obesity prevention-related recommendations, identifying a set of critical recommendations for future action, and recommending indicators of progress in implementing these actions [the charge]*5/4/2012Acknowledge the members of the committee.

*5/4/2012The committee looked at all major reports published that provided multilevel, multisector (population-based) obesity prevention-related evidence-based recommendations. This comprehensive review reflects recommendations from experts over the past 10 years across the nation convened by the government; state, local, and national organizations; foundations; the private sector; and partnerships between them. To give you a sense of the sources of these recommendations, listed is a sampling of the organizations from where these recommendations came frommany of you in the room are or have been part of a number of these activities and the organizations associated with them.

The year 2005 marked the beginning of the IOM issuance of obesity prevention-related recommendations demonstrating the complex, multifacted nature of the many factors that influence energy balance. Since then, a number of reports have been released; many of them focused on actions for specific aspects of obesity prevention (e.g., food marketing, school foods, early childhood policies).

The sheer number of these evidence based recommendations (approximately 800 of them over the past decade) reinforces the need for organization and guidance for focused action

*5/4/2012GoalsUtilizing the committees guiding principles, the committee identified 5 goals that helps sum up the actions that we recommended:

Integrate Physical Activity Every Day in Every WayMake Healthy Foods Available EverywhereMarket What Matters for a Healthy LifeActivate Employers and Health Care ProfessionalsStrengthen Schools as the Heart of Health

In other words, focused action is needed in 5 critical areas: physical activity; food and beverage; message; health care and work; and school.

Recommendations

The committee then developed 5 recommendations with these goals in mind. For example, for the first goal, the committees recommendation is Communities, transportation officials, community planners, health professionals, and governments should make promotion of physical activity a priority by substantially increasing access to places and opportunities for such activity.

Strategies

For each recommendation, the committee also identified 3-5 strategies that if acted upon, would have the greatest potential reach and impact on preventing obesity.

For example, for the first recommendation, increasing access to places and opportunities for such activity, the strategies for acceleration in this area include: (1) enhancing the built environment; (2) providing and supporting community programs; (3) adopting physical activity requirements for licensed child care providers; and (4) providing support for the science and practice of physical activity.

Action Sets

For each strategy, the committee also devised a set of actions that would likely make a positive contribution to the implementation of the strategy based on research evidence. In cases where evidence is lacking or limited, the action steps have a logical connection with the strategys implementation.

For example: potential actions to enhance the built environment include developing and implementing sustainable strategies fro improving the physical environment of communities; and developing and maintaining sustainable strategies to create and enhance access to places and programs, both to encourage and support physical activity in a safe and enjoyable way.

The details of these goals, recommendations, strategies, and the action sets for implementation can be found in the insert of the report brief that was handed out.

*5/4/2012*Why is PA a top priority? Only 19% of Americans get the recommended 60 minutes of daily PA

5/4/2012*Note that physical education and opportunities for physical activity in schools are covered in Recommendation 5, on school environments.

Strategy 1-1: Communities, organizations, community planners, and public health professionals should encourage physical activity by enhancing the physical and built environment, rethinking community design, and ensuring access to places for such activity.

Strategy 1-2: Communities and organizations should encourage physical activity by providing and supporting programs designed to increase such activity.

Develop and implement ongoing PA promotion campaigns involving high-visibility, multiple delivery channels and multiple sectors of influence Develop and implement PA strategies that fit into peoples daily routines and that are tailored to specific interests and preferences Develop and implement strategies to maintain social networks and to support behavior change re: PA

Strategy 1-3: State and local child care and early childhood education regulators should establish requirements for each program to improve its current physical activity standards.

State and local child care and early child care regulators should establish requirements for each program to improve current PA standards.Require licensed providers to provide PA opportunities including free and structured play at a rate of 15 mins/hour of careat a minimum, 30 minutes PA/day for day programs and 1 hour/day for full day programs

Strategy 1-4: Federal, state, and local government agencies should make physical activity a national health priority through support for the translation of scientific evidence into best-practice applications.

Feds: establish processes for regular and routine communication of latest available science related to the health benefits of PA could be done through regularly scheduled updates to PA Guidelines for Americans (akin to the 5-year cycle for the DGA) and updates of Surgeon Generals report (last issued in 1996)Develop priority strategies to promote and support the National PA Plantrans-sector strategy for increasing PAdirectly ties in with the committees systems thinking approach

State/local:Develop plans/strategies for making PA a health priority5/4/2012*Additional recommendation language: The business community/private sector includes private employers and privately owned and/or operated locations frequented by the public, such as movie theaters, shopping centers, sporting and entertainment venues, bowling alleys, and other recreational/entertainment facilities.

Although there is no consensus on the definition of unhealthy foods/beverages, the term refers in this report to foods and beverages that are calorie-dense and low in naturally occurring nutrients. Such foods and beverages contribute little fiber and few essential nutrients and phytochemicals, but contain added fats, sweeteners, sodium, and other ingredients. Unhealthy foods and beverages displace the consumption of foods recommended in the Dietary Guidelines for America and may lead to the development of obesity.

5/4/2012*Strategy 2-1: Decision makers in the business community/private sector, in nongovernmental organizations, and at all levels of government should adopt comprehensive strategies to reduce overconsumption of sugar-sweetened beverages. Sugar-sweetened beverages are defined to include all beverages containing added caloric sweeteners, including, but not limited to, sugar- or otherwise calorically sweetened regular sodas, less than 100 percent fruit drinks, energy drinks, sports drinks, and ready-to-drink teas and coffees

Action steps: Schools/locations where children cared for: ban SSBs, make clean potable water available; provide variety bevs recommended by DGA Business, private sector, govts, nongovtl: clean potable H20 in public places, variety bev options competitively $; fiscal policiesboth incentivizing healthy options and taxing SSBs with $ dedicated to obesity prevention programs; develop social marketing and education campaigns Industry: develop/promote range bev options including dev range healthy options with reduced sugar content and smaller portion sizes. Health care providers: screen for excess consumption SSBs and counsel on health risks associated

Strategy 2-2: Chain and quick-service restaurants should substantially reduce the number of calories served to children and substantially expand the number of affordable and competitively priced healthier options available for parents to choose from in their facilities.

In recent years, several fast-food and chain outlets have started developing healthier options for childrens meals. In 2011 the National Restaurant Association announced an initiative in which 19 chains, including Burger King, agreed to provide at least one childrens meal option with no more than 600 calories (graphic). Now, more than 50 chains are participating.

Strategy 2-3: Government agencies (federal, state, local, and school district) should ensure that all foods and beverages sold or provided through the government are aligned with the age-specific recommendations in the current Dietary Guidelines for Americans. fed/state/local healthy vending/concession standards

The business community and the private sector operating venues frequented by the public should ensure that a variety of foods and beverages, including those recommended by the Dietary Guidelines for Americans, are sold or served at all times and are competitively priced and available for purchase/consumption.Action steps:

Strategy 2-4: States and localities should utilize financial incentives such as flexible financing or tax credits, streamlined permitting processes, and zoning strategies, as well as cross-sectoral collaborations (e.g., among industry, philanthropic organizations, government, and the community) to enhance the quality of local food environments, particularly in low-income communities.

These efforts should include encouraging or attracting retailers and distributors of healthy food (e.g., supermarkets) to locate in underserved areas and limiting the concentration of unhealthy food venues (e.g., fast-food restaurants, convenience stores). Incentives should be linked to public health goals in ways that give priority to stores that also commit to health-promoting retail strategies (e.g., through placement, promotion, and pricing).

Strategy 2-5: Congress, the administration, and federal agencies should examine the implications of U.S. agriculture policy for obesity, and should ensure that such policy includes understanding and implementing, as appropriate, an optimal mix of crops and farming methods for meeting the Dietary Guidelines for Americans.

5/4/2012*5/4/2012*Strategy 3-1: Congress, the administration, other federal policy makers, and foundations should dedicate substantial funding and support to the development and implementation of a robust and sustained social marketing program on physical activity and nutrition. This program should encompass carefully targeted, culturally appropriate messages aimed at specific audiences (e.g., tweens, new parents, mothers); clear behavior-change goals (e.g., take a daily walk, reduce consumption of sugar-sweetened beverages among adolescents, introduce infants to vegetables, make use of the new front-of-package nutrition labels); and related environmental change goals (e.g., improve physical environments, offer better food choices in public places, increase the availability of healthy food retailing).

Strategy 3-2: The food, beverage, restaurant, and media industries should take broad, common, and urgent voluntary action to make substantial improvements in their marketing aimed directly at children and adolescents aged 2-17. All foods and beverages marketed to this age group should support a diet that accords with the Dietary Guidelines for Americans in order to prevent obesity and risk factors associated with chronic disease risk. Children and adolescents should be encouraged to avoid calories from foods that they generally overconsume (e.g., products high in sugar, fat, and sodium) and to replace them with foods they generally underconsume (e.g., fruits, vegetables, and whole grains). The standards set for foods and beverages marketed to children and adolescents should be widely publicized and easily available to parents and other consumers. They should cover foods and beverages marketed to children and adolescents aged 2-17 and should apply to a broad range of marketing and advertising practices, including digital marketing and the use of licensed characters and toy premiums. If such marketing standards have not been adopted within 2 years by a substantial majority of food, beverage, restaurant, and media companies that market foods and beverages to children and adolescents, policy makers at the local, state, and federal levels should consider setting mandatory nutritional standards for marketing to this age group to ensure that such standards are implemented. Strategy 3-3: The Food and Drug Administration (FDA) and the U.S. Department of Agriculture (USDA) should implement a standard system of nutrition labeling for the front of packages and retail store shelves that is harmonious with the Nutrition Facts panel, and restaurants should provide calorie labeling on all menus and menu boards.

Strategy 3-4: USDA should update the policies for Supplemental Nutrition Assistance Program Education (SNAP-Ed) and the policies for other federal programs with nutrition education components to explicitly encourage the provision of advice about types of foods to reduce in the diet, consistent with Dietary Guidelines for Americans. 5/4/2012*5/4/2012*Strategy 4-1: All health care providers should adopt standards of practice (evidence-based or consensus guidelines) for prevention, screening, diagnosis, and treatment of overweight and obesity to help children, adolescents, and adults achieve and maintain a healthy weight, avoid obesity-related complications, and reduce the psychosocial consequences of obesity. Health care providers should also advocate, on behalf of their patients, for improved physical activity and diet opportunities in their patients communities.

Strategy 4-2: Insurers (both public and private) should ensure that health insurance coverage and access provisions address obesity prevention, screening, diagnosis, and treatment.

Strategy 4-3: Worksites should create, or expand, healthy environments by establishing, implementing, and monitoring policy initiatives that support wellness.

Strategy 4-4: Health service providers and employers should adopt, implement, and monitor policies that support healthy weight gain during pregnancy and the initiation and continuation of breastfeeding. Population disparities in breastfeeding should be specifically addressed at the federal, state, and local levels to remove barriers and promote targeted increases in breastfeeding initiation and continuation.5/4/2012*5/4/2012*Strategy 5-1: Through support from federal and state governments, state and local education agencies and local school districts should ensure that all students in grades K-12 have adequate opportunities to engage in 60minutes of physical activity per school day. This 60-minute goal includes access to and participation in quality physical education.

Strategy 5-2: All government agencies (federal, state, local, and school district) providing foods and beverages to children and adolescents have a responsibility to provide those in their care with foods and beverages that promote their health and learning. The 2010 Dietary Guidelines for Americans provide specific science-based recommendations for optimizing dietary intake to prevent disease and promote health. Implementation of these guidelines would shift childrens and adolescents dietary intake to prevent obesity and risk factors associated with chronic disease risk by increasing the amounts of fruits, vegetables, and high-fiber grains they consume; decreasing their consumption of sugar-sweetened beverages, dietary fat in general, solid fats, and added sugars; and ensuring age-appropriate portion sizes of meals and other foods and beverages. Federal, state, and local decision makers are responsible for ensuring that nutrition standards based on the Dietary Guidelines are adopted by schools; these decision makers, in partnership with regulatory agencies, parents, teachers, and food manufacturers, also are responsible for ensuring that these standards are implemented fully and that adherence is monitored so as to protect the health of the nations children and adolescents.

Strategy 5-3: Through leadership and guidance from federal and state governments, state and local education agencies should ensure the implementation and monitoring of sequential food literacy and nutrition science education, spanning grades K-12, based on the food and nutrition recommendations in the Dietary Guidelines for Americans. 5/4/2012*In addition to these bold, evidence-based recommendations and strategies there are critical components introduced within this report that the committee believes are essential to accelerating progress in obesity prevention.

These interrelated components include taking a systems approach, achieving equity, engagement to mobilize change, and inspiring leadership.

Together these will catalyze and ensure the system-wide adoption of the committees recommendations.

*5/4/2012Or more simplya visual of the five areas that the recommendations fall within, and their broad interactions.

What these interactions help illustrate is how one recommendation may reinforce another recommendation.

For example, within the report, schools are called on as a national focal point of obesity prevention.

However, schools cannot solve obesity alone.There are a number of things that the committee recommends schools can do. For example provide opportunities for 60 minutes of physical activity including quality physical education, ensure the availability of healthy foods and beverages, and offer nutrition education.

But if these strategies are not reinforced everywhere else, or worse undermined, then progress cannot be accelerated. For example if children are exposed to relentless advertising of unhealthy foods and beverages on TV and the Internet; if healthy food options in the community are unavailable and unaffordable; and if there are no safe places for kids to play. *5/4/2012Accelerating obesity prevention includes accelerating progress in reducing disparities in obesity prevalence. Obesity affects all segments of the population, but environmental conditions contribute to the disproportionate burden of obesity and the related social and economic burdens among individuals in racial/ethnic minority or low-income populations. This means that the starting point, both in terms of the higher levels of prevalence and the conditions that have to be changed pose greater challenges for effective implementation of our recommendationschallenges that we must meet as a high priority. A situation where we declare victory of the obesity epidemic, except for those with the highest risk and fewest resources to effect changes is untenable.

To highlight some of the evidence we considered:Physical activity environments are key settings for accelerating obesity prevention, but opportunities for safe and affordable leisure-time activity are less available in racial/ethnic minority and low-income communities. The lowest cost foods and beverage may be the least healthy and highest in calories, which means that people with low incomes may need to rely on these foods to a much greater extent than people with higher incomes.Message environments in many ethnic minority and low income communities are dominated by advertisements and other promotions of high calorie foods and beverages generallyin stores, around stores, and on billboards to a significantly greater extent than applies to predominantly white or higher income communities. Black and Latino children and low income children rely heavily on television and electronic media as sources of entertainment and are exposed disproportionately to ads for high calorie foods and beverages through these sources.TV ads on shows watched by black audiences have more food ads and these ads are for unhealthy foodsThe mix of foods available in low income communities presents a plethora of high calorie options, marketing in quantities and at prices and even in culturally tailored ways that are very attractive to community residents. Sometimes these are the only convenient options.

What this means is that the committee recommendations about transforming environment takes on special significance. ..*5/4/2012There is an urgent need to employ large-scale transformative approaches focused on multilevel environmental and policy changes within interconnected systems to reduce the threat of obesity and sustain an enduring impact.

Another way to say that is to use a motto from native Hawaiian lore working together we make progress

So Unlike many reports before this is not a report on what doctors can do alone or what schools should do alone or what workplace programs can do alone or what individuals can and should do themselves

It IS about an urgent need to move collectively, to mobilize in a way the nation has never done before and it needs everyone in this room and the organizations and connections we have to make the impact necessary.

In closing,

Understanding interactions will accelerate the realization of this vision.

Achieving this vision will involve mobilizing the population through engagement and leadership at all levelsindividuals, families, communities, and societyand in all sectors.

Targeted actions are needed to reduce the inequitable distribution of health promotion resources and risk factors that contribute to health disparities in low-income, minority, and other disadvantaged populations.

And, our efforts must be assessed and progress documented and ineffectiveness deleted

The committees hope is that every individual will be ready and willing to do their part to accelerate progress in obesity prevention. *5/4/2012On their own, any one of these five solutions might help speed up progress in preventing obesity, but together, their effect would be reinforced, amplified, and maximized.

Do it all Do it now All of us*5/4/20125/4/2012*