ISSUE REPORT F as in Fat: 2007 HOW OBESITY POLICIES ARE FAILING IN AMERICA AUGUST 2007 PREVENTING EPIDEMICS. PROTECTING PEOPLE. TRUST FOR AMERICA’S HEALTH IS A NON-PROFIT, ACKNOWLEDEMENTS NON-PARTISAN ORGANIZATION DEDICATED TO SAVING This report is supported by a grant from the Robert LIVES BY PROTECTING THE HEALTH OF EVERY COMMUNITY W ood Johnson Foundation. The opinions expressed in AND WORKING TO MAKE DISEASE PREVENTION A this report are those of the authors and do not neces- sarily reflect the views of the foundation. NATIONAL PRIORITY. TFAH BOARD OF DIRECTORS Lowell Weicker, Jr. Patricia Bauman, MS, JD President Treasurer Former three-term U.S. Senator and President and CEO Governor of Connecticut Bauman Foundation Cynthia M. Harris, PhD, DABT John W. Everets Vice President Alonzo Plough, MA, MPH, PhD Director and Associate Professor Vice President of Program, Planning, and Evaluation Institute of Public Health, Florida A & M University The California Endowment Margaret A. Hamburg, MD Theodore Spencer Secretary Project Manager Senior Scientist National Resources Defense Council Nuclear Threat Initiative (NTI) REPORT AUTHORS Jeffrey Levi, PhD Laura M. Segal, MA Executive Director Director of Public Affairs Trust for America’s Health Trust for America’s Health Emily Gadola, MPP Public Affairs Research Associate Trust for America’s Health CONTRIBUTORS Chrissie Juliano, MPP Ilyse Veron Public Affairs Research Associate Senior Communications Manager Trust for America’s Health Trust for America’s Health PEER REVIEWERS TFAH thanks the reviewers for their time, expertise, and insights. The opinions expressed in this report do not necessarily represent the views of these individuals or their organizations. Katie Clarke Adamson Marcus Plescia, MD, MPH Director of Health Partnerships and Policy Chief, Chronic Disease and Injury Section YMCA of the USA North Carolina Division of Public Health Sheila Franklin Kimberly F. Stitzel, MS, RD Marketing and Communications Manager Science and Medicine Advisor National Coalition for Promoting Physical Activity American Heart Association David P. Hoffman, MEd Monica Hobbs Vinluan, JD Director Senior Policy Associate Bureau of Chronic Disease Services New York State National Parks and Recreation Association Jeffrey P. Koplan, MD, MPH Vice President for Academic Health Affairs Woodruff Health Science Center Director, Global Health Institute Emory University Introduction O besity has dominated media headlines over the past few years as the nation has begun to recognize it is a serious health crisis. Two-thirds of American adults are obese or tion and minimum levels of physical activity overweight, and in the past year, obesity rates for sustaining good health. have continued to rise in 31 states. Eighty-five However, much less is known about how to percent of Americans believe that obesity is an effectively encourage people to make epidemic, according to a new poll conducted healthy choices. Individuals are often told by Trust for America’s Health (TFAH).1 to take personal responsibility and lose Poor nutrition and physical inactivity are weight. However, with two-thirds of increasing Americans’ risk for developing American adults obese or overweight, many major diseases, including type 2 diabetes, heart Americans are struggling with their weight. disease and stroke and some forms of cancer.2 More than $35 billion is spent annually on weight loss-related products and services.3 But while the obesity epidemic has garnered Clearly, the strategy of focusing on personal increased attention, a comparable increase responsibility alone is failing. in action has yet to occur. People do not make decisions in a vacuum. While many promising efforts are being ini- They are influenced by their relationships tiated across the country, there is no nation- with family, friends, neighbors, and col- al commitment to addressing the problem. leagues; their home, workplace, neighbor- Researchers and practitioners know a lot hood, and school environments; their eco- about nutrition and exercise. There are nomic limitations; and their genetics, physi- well agreed upon standards for basic nutri- ology, psychology, and life stages. OBESITY IS WEIGHING US DOWN: NATIONAL ACTION NEEDED The country needs to develop a plan for healthy and productive. Obesity related combating obesity that is in proportion to health care costs are draining dollars from the scope and depth of the problem. This the bottom line of businesses. will require focusing on strategies that will The future health of the country requires us work on a wide scale. to invest in changes that will make it easier The question is, is America willing to make to help people make healthier choices. the commitment needed to return to better These include making changes to our health? schools, our workplaces, our homes, and Today’s children are likely to be the first gen- our communities. The crisis requires every- eration to live shorter, less healthy lives than one to engage: government at all levels, their parents. Approximately 25 million businesses -- big and small, health care children are already obese or overweight.4 providers, community groups, and families. The crisis has an impact beyond individual This fourth annual edition of the F as in Fat: health. U.S. economic competitiveness is How Obesity Policies Are Failing in America hurting as our workforce becomes less report explores both the current policy weak- 3 nesses and the new, grand scale changes that federal and state level. It also offers an in need to be considered to address the obesity depth examination of physical activity crisis nationwide. While we need to make big including a cost review, consensus-based rec- changes to the places we live, work, and play ommendations and strategies to encourage to help improve our health, the good news is activity, and a description of barriers that that research shows even small changes in deter people from engaging in enough individuals can have big health benefits. physical activity. Previous editions of the report have detailed The report also includes findings about how obesity and related disease rates have potential strategies for dealing with obesity been climbing in the U.S. While it is a from 2 surveys, one of on the ground experts national problem, the Southern states expe- and the other of average citizens. Chronic rience higher rates than the rest of the Disease Directors and Directors of Health nation, calling for increased attention on Promotion and Education, who are on the understanding the factors that contribute to ground experts, provide their assessment of these regional disparities. different strategies for combating obesity, and Americans weigh in through a public The F as in Fat reports have examined a opinion survey about the obesity epidemic range of federal and state policies, includ- and possible strategies for dealing with it. ing school nutrition and physical activity requirements, community approaches such The various policies and approaches dis- as snack taxes, smart growth community cussed in the report help build a national design initiatives, and other public health evidence base for what efforts are effective programs. The reports have also reviewed as the country seeks improved strategies for intervention approaches to help inform the addressing the obesity epidemic. These development of future strategies. efforts provide information about ways to more effectively encourage people to make This year’s report provides an update of healthy choices. trends in obesity rates and policies at the TABLE OF CONTENTS Section 1: Obesity Rates and Related Trends: Review of obesity, weight-related health diseases, and physical inactivity rates in states; Section 2: Obesity and State Policy: An update of trends in obesity-related state legislation and initiatives; Section 3: Obesity and Federal Policy: An update of federal obesity-related initia- tives; Section 4: Focus on Physical Activity: An in depth focus on physical activity and potential strategies for encouraging increased activity; Section 5: Experts Survey: A survey of experts about their on the ground assess- ment of potential strategies; Section 6: Public Opinion Survey: A public opinion survey about obesity and strategies for combating obesity; and Section 7: Recommendations. 4 Obesity Rates and Related Trends 1 SECTION T wo-thirds of American adults are either overweight or obese in America.5 Adult obesity rates have grown from 15 percent in 1978-80 to 32 percent in 2003-04 based on a national survey.6 OBESITY TRENDS* AMONG U.S. ADULTS BRFSS, 1991 and 2004-2006 Combined Data (*BMI >30, or about 30 lbs overweight for 5’ 4” person) *Source: Behavioral Risk Factor Surveillance System, CDC. A. ADULT OBESITY AND OVERWEIGHT RATES In the past year, obesity rates continued to Adult obesity rates currently exceed 25 rise in 31 states. Twenty-two of these states percent in 19 states, an increase from 14 experienced an increase for the second year states last year. in a row. Obesity rates have not dropped in Adult obesity rates exceed 20 percent in 47 a single state. states and D.C., an increase from 43 states Nearly one in 3 adults -- 30.6 percent -- are and D.C. last year. In Colorado, the leanest now reported to be obese in Mississippi, rep- state, adult obesity rates increased from 16.9 resenting the first time adult obesity rates percent to 17.6 percent in the past year. have exceeded 30 percent in a single state. The U.S. Department of Health and Human Mississippi also has the highest adult hyper- Services (HHS) set a national goal aiming to tension rate, the highest rate of physical reduce adult obesity levels to 15 percent in inactivity, the second highest rate of adult every state by the year 2010. diabetes, and the highest rate of poverty (tied with D.C.). 5 CHART ON OBESITY AND ADULTS Obesity Overweight Diabetes Physical Inactivity & Obesity States 2004-2006 3 Yr. Ranking Percentage 2004-2006 2004-2006 3 Yr. Ave. Ranking 2004-2006 Ranking Ave Percentage Point Change 3 Yr. Ave. Percentage 3 Yr. Ave. (95% Conf Interval) 2003-2005 to Percentage (95% Conf Interval) Percentage 2004-2006 (95% Conf (95% Conf Interval) Interval) Alabama 29.4% (+/- 1.2) 3 0.7 64.7% (+/- 1.3) 9.3% (+/- 0.6) 5 29.5% (+/- 1.1) 5 Alaska 25.8% (+/- 1.4) 16 0.9 63.7% (+/- 1.6) 4.8% (+/- 0.6) 50 21.1% (+/- 1.3) 39 Arizona 21.7% (+/- 1.4) 43 0.9 57.3% (+/- 1.7) 7.6% (+/- 0.7)* 21 23.0% (+/- 1.4) 25 Arkansas 27.0% (+/- 0.9) 8 0.6 63.7% (+/- 1.0) 7.8% (+/- 0.5) 16 28.6% (+/- 0.9) 7 California 22.7% (+/- 0.9) 36 0.0 59.9% (+/- 1.0) 7.4% (+/- 0.5) 23 23.2% (+/- 0.9) 24 Colorado 17.6% (+/- 0.7)* 51 0.8* 54.2% (+/- 0.9)* 4.8% (+/- 0.3) 50 17.8% (+/- 0.7) 48 Connecticut 20.1% (+/- 0.7)* 47 0.5** 57.7% (+/- 1.0)* 6.3% (+/- 0.4) 42 20.0% (+/- 0.7) 42 Delaware 23.6% (+/- 1.1)* 29 0.7** 62.2% (+/- 1.2)* 7.9% (+/- 0.6) 15 22.2% (+/- 1.0)^ 31 D.C. 22.2% (+/- 1.1) 40 0.7 55.0% (+/- 1.3) 7.8% (+/- 0.6) 16 22.3% (+/- 1.1) 30 Florida 22.9% (+/- 0.8)* 34 1.1** 60.0% (+/- 0.9) 8.4% (+/- 0.5) 10 25.2% (+/- 0.8)^ 15 Georgia 26.1% (+/- 1.0) 14 0.6 61.4% (+/- 1.1) 8.3% (+/- 0.5)* 11 25.9% (+/- 0.9) 13 Hawaii 20.1% (+/- 1.0)* 47 2.0* 54.5% (+/- 1.2)* 7.8% (+/- 0.6) 16 19.4% (+/- 0.9) 44 Idaho 23.2% (+/- 0.8) 31 0.8 59.8% (+/- 1.0) 6.6% (+/- 0.4) 38 20.5% (+/- 0.8)* 40 Illinois 24.4% (+/- 0.9) 25 0.5 60.7% (+/- 1.0) 7.4% (+/- 0.5) 23 24.3% (+/- 0.9)^ 22 Indiana 26.8% (+/- 0.8) 9 0.6 62.5% (+/- 0.9) 8.0% (+/- 0.4) 14 25.9% (+/- 0.7) 13 Iowa 24.9% (+/- 0.8) 20 0.6 62.1% (+/- 1.0) 6.8% (+/- 0.4) 35 22.8% (+/- 0.8) 26 Kansas 24.3% (+/- 0.6)* 27 1.1* 61.3% (+/- 0.8) 6.9% (+/- 0.3)* 34 23.4% (+/- 0.6)* 23 Kentucky 27.5% (+/- 1.0)* 7 0.8** 64.9% (+/- 1.1)* 8.8% (+/- 0.5)* 8 30.6% (+/- 1.0) 3 Louisiana 28.2% (+/- 0.9) 4 0.8 63.4% (+/- 1.0) 8.9% (+/- 0.5) 7 31.3% (+/- 0.9) 2 Maine 23.0% (+/- 0.9)* 33 1.0* 60.1% (+/- 1.1) 7.3% (+/- 0.5) 27 21.6% (+/- 0.9) 36 Maryland 24.4% (+/- 0.8)* 25 1.0** 60.1% (+/- 1.0) 7.4% (+/- 0.5) 23 22.6% (+/- 0.8) 27 Massachusetts 19.8% (+/- 0.7)* 50 1.2** 55.3% (+/- 0.9)* 6.1% (+/- 0.3) 45 21.5% (+/- 0.7) 37 Michigan 26.8% (+/- 0.8)* 9 1.2* 62.7% (+/- 0.9)* 8.3% (+/- 0.4) 11 22.5% (+/- 0.7) 28 Minnesota 23.7% (+/- 1.0) 28 0.6 61.3% (+/- 1.1) 5.5% (+/- 0.4) 48 15.4% (+/- 0.8) 51 Mississippi 30.6% (+/- 0.9)* 1 1.1** 66.5% (+/- 1.0) 10.1% (+/- 0.5) 2 31.6% (+/- 0.9) 1 Missouri 26.3% (+/- 1.0)* 12 1.2** 62.8% (+/- 1.2)* 7.5% (+/- 0.5) 22 24.5% (+/- 1.0) 19 Montana 20.7% (+/- 0.8) 45 0.8 58.0% (+/- 1.1) 6.0% (+/- 0.4) 46 20.2% (+/- 0.8) 41 Nebraska 25.4% (+/- 0.8)* 18 1.0** 63.0% (+/- 0.9)* 7.0% (+/- 0.4)* 31 22.1% (+/- 0.7) 32 Nevada 22.5% (+/- 1.3)* 37 1.5* 60.8% (+/- 1.5)* 7.0% (+/- 0.7) 31 26.1% (+/- 1.4) 12 New Hampshire 22.4% (+/- 0.8)* 38 0.7** 59.5% (+/- 0.9)* 6.8% (+/- 0.4)* 35 19.9% (+/- 0.7) 43 New Jersey 22.2% (+/- 0.6)* 40 0.8** 59.6% (+/- 0.7)* 7.3% (+/- 0.3) 27 27.3% (+/- 0.6) 9 New Mexico 22.0% (+/- 0.8)* 42 0.8** 59.3% (+/- 1.0)* 7.1% (+/- 0.4)* 29 22.4% (+/- 0.8) 29 New York 22.4% (+/- 0.8) 38 0.7 58.6% (+/- 0.9) 7.8% (+/- 0.5) 16 26.5% (+/- 0.8) 10 North Carolina 25.6% (+/- 0.5)* 17 0.9** 62.3% (+/- 0.6) 8.7% (+/- 0.3)* 9 24.7% (+/- 0.5) 18 North Dakota 25.1% (+/- 1.0) 19 0.6 63.8% (+/- 1.1) 6.4% (+/- 0.5) 41 22.1% (+/- 0.9) 32 Ohio 26.0% (+/- 1.2)* 15 1.1** 62.5% (+/- 1.3) 7.4% (+/- 0.6)^ 23 24.4% (+/- 1.1) 20 Oklahoma 26.8% (+/-0.8)* 9 1.4** 62.9% (+/- 0.9)* 9.0% (+/- 0.4)* 6 29.4% (+/- 0.8) 6 Oregon 23.3% (+/- 0.8)* 30 1.1** 59.8% (+/- 0.9) 6.7% (+/- 0.4) 37 17.4% (+/- 0.7)^ 49 Pennsylvania 24.5% (+/- 0.7) 23 0.1 61.4% (+/- 0.9) 8.2% (+/- 0.4) 13 24.4% (+/- 0.7) 20 Rhode Island 20.5% (+/- 0.9)* 46 1.0** 58.8% (+/- 1.2)* 7.0% (+/- 0.5) 31 25.0% (+/- 1.0) 16 South Carolina 27.8% (+/- 0.7)* 5 1.6** 63.7% (+/- 0.8)* 9.4% (+/- 0.4) 3 24.8% (+/- 0.7) 17 South Dakota 24.9% (+/- 0.8)* 20 0.9** 62.9% (+/- 1.0)* 6.5% (+/- 0.4) 40 21.8% (+/- 0.8)* 34 Tennessee 27.8% (+/- 1.2)* 5 1.3* 63.9% (+/- 1.2)* 9.4% (+/- 0.6) 3 30.5% (+/- 1.1) 4 Texas 26.3% (+/- 0.9) 12 0.5 63.1% (+/- 1.1) 7.8% (+/- 0.5) 16 27.4% (+/- 0.9) 8 Utah 21.1% (+/- 0.8) 44 0.3 55.8% (+/- 1.1) 5.4% (+/- 0.4) 49 18.3% (+/- 0.8) 47 Vermont 20.0% (+/- 0.6) 49 0.5 55.4% (+/- 0.8) 5.8% (+/- 0.3) 47 18.4% (+/- 0.6) 46 Virginia 24.5% (+/- 1.0)* 23 1.1* 61.0% (+/- 1.2)* 7.1% (+/- 0.5) 29 21.7% (+/- 0.9) 35 Washington 23.2% (+/- 0.5)* 31 0.8** 59.5% (+/- 0.5)* 6.6% (+/- 0.2) 38 17.3% (+/- 0.4) 50 West Virginia 29.8% (+/- 1.0)* 2 1.1* 65.5% (+/- 1.1)* 11.1% (+/- 0.6)* 1 26.2% (+/- 1.0)^ 11 Wisconsin 24.8% (+/- 0.9)* 22 1.9** 61.8% (+/- 1.1)* 6.2% (+/- 0.4) 44 18.8% (+/- 0.8) 45 Wyoming 22.8% (+/- 0.8)* 35 1.1** 60.2% (+/- 1.0)* 6.3% (+/- 0.4) 42 21.3% (+/- 0.8) 38 Source: Behavior Risk Factor Surveillance System (BRFSS), CDC. To stabilize BRFSS data in order to rank states, TFAH combined three years of data (See Appendix A for more information on the methodology used for the rankings.). * & Red indicates a statistically significant change (P<0.05) from 2003-2005 to 2004-2006 (for Hypertension figures -- only collected every two years -- from 1999-2003 to 2001-2005). **State increased the past two years. ^Statistically significant DECREASE. Source: U.S. Census Bureau, Table 8 <http://www.census.gov/hhes/www/poverty/poverty05/table8.html> 6 OVERWEIGHT IN THE STATES CHILDREN Hypertension Poverty 2005 YRBSS 2005 PedNSS 2003-04 National Survey of Children’s Health 2001-2005 Ranking 2003-2005 Percentage Percentage Percentage Percentage Percentage Ranking Percentage Participating 3 Yr. Ave. 3 Yr. Ave. Overweight High School Students At High School Students Overweight Overweight in Physical Activity Percentage Percentage High School Risk of Overweight Not Meeting Low-Income Ages 10-17 >20 mins 3 Days a Week (95% Conf (90% Conf Interval) Students (95% (95% Conf Interval) Recommended Children Ages 2-5 or More Ages 10-17 Interval) Conf Interval) Physical Activity Level 32.0% (+/- 1.1) 3 16.2% (+/- 1.5) 14.8% (+/- 1.7) 16.7% (+/- 1.6) 68% 12.9% 16.7% 11 77.6% 21.4% (+/- 1.2) 48 9.6% (+/- 1.3) N/A N/A N/A N/A 11.1% 44 75.5% 22.9% (+/- 1.1)* 44 14.4% (+/- 1.4) 11.9% (+/- 2.0) N/A 68% 14.7% 12.2% 38 72.7% 29.8% (+/- 0.9) 5 15.6% (+/- 1.6) 15.4% (+/- 1.9) N/A 69% 11.2% 16.4% 12 71.9% 24.1% (+/- 0.8)* 33 13.2% (+/- 0.6) N/A N/A N/A 15.9% 13.2% 32 74.9% 20.5% (+/- 0.9) 50 10.4% (+/- 1.3) 9.8% (+/- 2.8) 10.3% (+/- 2.3) N/A 8.5% 9.9% 49 70.4% 24.0% (+/- 0.7)* 35 9.2% (+/- 1.2) 11.2% (+/- 2.4) 14.7% (+/- 1.8) N/A 12.7% 12.3% 37 68.5% 27.7% (+/- 1.0) 12 8.5% (+/- 1.2) 14.1% (+/- 1.4) 15.1% (+/- 1.6) N/A N/A 14.8% 19 65.7% 27.1% (+/- 1.3) 15 18.3% (+/- 1.9) 10.6% (+/- 1.5) N/A N/A 13.5% 22.8% 1 62.1% 28.0% (+/- 0.9) 11 11.8% (+/- 0.7) 10.9% (+/- 1.0) 14.4% (+/- 1.2) N/A 13.3% 14.4% 21 68.9% 27.1% (+/- 0.9) 15 13.1% (+/- 1.1) 12.4% (+/- 2.1) 14.9% (+/- 1.9) 66% 14.3% 16.4% 12 69.1% 23.8% (+/- 0.9) 37 8.8% (+/- 1.2) 13.5% (+/- 1.9) 14.2% (+/- 1.9) 70% N/A 13.3% 29 75.2% 23.8% (+/- 0.8) 37 10.0% (+/- 1.3) 7.2% (+/- 1.6) 13.7% (+/- 2.4) 61% 10.0% 10.1% 47 70.5% 24.8% (+/- 0.9) 27 12.1% (+/- 0.8) N/A N/A N/A 12.3% 15.8% 14 71.1% 26.3% (+/-0.8) 20 11.4% (+/- 1.1) 15.0% (+/- 2.5) 14.3% (+/- 1.3) N/A 11.9% 15.6% 15 70.7% 25.0% (+/- 0.8) 26 10.4% (+/- 1.3) 12.2% (+/- 2.8) 14.8% (+/- 2.1) 66% 14.1% 12.5% 35 74.8% 23.8% (+/- 0.7)* 37 11.6% (+/- 1.4) 11.9% (+/- 2.0) 13.3% (+/- 1.8) N/A 14.0% 14.0% 24 76.6% 29.4% (+/- 0.9) 7 15.6% (+/- 1.6) 15.6% (+/- 1.5) 17.0% (+/- 1.7) N/A 17.1% 20.6% 3 68.4% 28.6% (+/- 0.9)* 9 17.4% (+/- 1.6) N/A N/A N/A N/A 17.2% 9 75.2% 25.6% (+/- 1.0) 24 11.9% (+/- 1.4) 10.9% (+/- 1.7) 14.4% (+/- 2.2) N/A N/A 12.7% 34 67.3% 25.8% (+/- 0.8) 21 9.4% (+/- 1.1) 12.6% (+/- 2.1) 16.1% (+/- 2.0) N/A 13.3% 13.3% 29 61.7% 23.8% (+/- 0.7)* 37 9.9% (+/- 1.0) 11.2% (+/- 2.0) 15.6% (+/- 1.5) N/A 14.9% 13.6% 27 67.6% 27.3% (+/- 0.8)* 13 12.2% (+/- 0.9) 12.1% (+/- 2.2) 13.5% (+/- 2.0) N/A 12.3% 14.5% 20 69.6% 22.1% (+/- 0.9) 47 7.5% (+/- 1.0) N/A N/A N/A 13.1% 10.1% 47 72.8% 32.7% (+/- 1.0) 1 18.3% (+/- 1.7) N/A N/A N/A N/A 17.8% 8 69.4% 27.1% (+/- 1.0)* 15 11.5% (+/- 1.2) 13.9% (+/- 2.4) 15.9% (+/- 1.8) 64% 11.8% 15.6% 15 72.1% 24.0% (+/- 1.0) 35 14.4% (+/- 1.6) 9.3% (+/- 1.3) 12.8% (+/- 1.2) 69% 12.8% 11.1% 44 76.4% 23.6% (+/- 0.8)* 42 9.6% (+/- 1.3) 11.0% (+/- 1.2) 13.8% (+/- 1.4) 64% 12.9% 11.9% 41 74.2% 24.6% (+/- 1.4)^ 30 10.8% (+/- 1.3) N/A N/A N/A 14.2% 12.4% 36 72.6% 22.9% (+/- 0.8) 44 5.6% (+/- 1.0) 11.4% (+/- 2.2) 13.2% (+/- 2.2) 57% 15.5% 12.9% 33 68.1% 25.7% (+/- 0.6) 22 7.8% (+/- 0.8) 11.4% (+/- 2.7) 15.4% (+/- 2.6) N/A 16.5% 13.7% 26 66.8% 21.4% (+/- 0.8)* 48 17.5% (+/- 1.8) 12.0% (+/- 2.2) 14.6% (+/- 1.9) N/A 10.8% 16.8% 10 69.9% 25.6% (+/- 0.8)* 24 14.6% (+/- 0.8) 10.5% (+/- 1.4) 17.1% (+/- 1.5) 70% 12.2% 15.3% 18 68.2% 28.4% (+/- 0.8)* 10 14.4% (+/- 1.1) 13.5% (+/- 2.5) 15.7% (+/- 1.7) 54% 14.7% 19.3% 5 74.4% 23.8% (+/- 0.9)^ 37 10.2% (+/- 1.3) 11.2% (+/- 2.4) 12.8% (+/- 1.6) N/A 13.6% 12.1% 39 75.4% 26.7% (+/- 1.0) 19 11.6% (+/- 0.9) 12.7% (+/- 2.7) 14.7% (+/- 2.3) N/A N/A 14.2% 22 69.9% 28.8% (+/- 0.8)* 8 13.1% (+/- 1.4) 15.2% (+/- 2.0) 15.9% (+/- 2.1) 62% N/A 15.4% 17 73.3% 24.2% (+/- 0.8) 32 12.1% (+/- 1.4) N/A N/A N/A N/A 14.1% 23 77.0% 27.3% (+/- 0.8)* 13 11.0% (+/- 0.8) N/A N/A N/A 11.0% 13.3% 29 67.9% 26.9% (+/- 0.9)* 18 11.7% (+/- 1.4) 12.9% (+/- 1.7) 15.2 % (+/- 1.9) N/A N/A 11.9% 41 63.8% 29.7% (+/- 0.8)* 6 14.2% (+/- 1.5) 12.7% (+/- 2.9) 13.7% (+/- 2.9) 70% 13.0% 18.9% 7 67.5% 24.7% (+/- 0.7) 29 12.7% (+/- 1.3) 10.4% (+/- 2.1) 14.0% (+/- 1.6) N/A 13.6% 12.1% 39 73.2% 29.9% (+/- 1.1) 4 15.0% (+/- 1.4) 14.6% (+/- 2.6) 17.5% (+/- 2.4) 66% 11.4% 20.0% 4 65.1% 24.8% (+/- 0.7) 27 16.5% (+/- 0.8) 13.9% (+/- 1.6) 15.0% (+/- 1.8) 64% 15.2% 19.1% 6 73.9% 19.8% (+/- 0.9)^ 51 9.4% (+/- 1.2) 5.6% (+/- 1.7) 11.1% (+/- 2.2) 64% 7.6% 8.5% 51 71.7% 22.8% (+/- 0.7)* 46 8.0% (+/- 1.2) 9.5% (+/- 2.1) 13.8% (+/- 1.3) N/A 11.7% 11.3% 43 73.5% 25.7% (+/- 0.9)* 22 9.5% (+/- 1.0) N/A N/A N/A 21.5% 13.8% 25 72.5% 24.1% (+/- 0.6) 33 11.4% (+/- 1.2) N/A N/A N/A N/A 10.8% 46 72.9% 32.5% (+/- 1.0) 2 15.6% (+/- 1.4) 14.5% (+/- 2.2 ) 16.0% (+/- 2.6) N/A 10.9% 20.9% 2 77.1% 24.5% (+/- 0.9) 31 10.8% (+/- 1.2) 9.9% (+/- 1.6) 13.7% (+/- 1.6) 65% 12.3% 13.5% 28 75.1% 23.2% (+/- 0.8) 43 10.1% (+/- 1.4) 8.4% (+/- 1.1) 12.3% (+/- 1.4) N/A 8.0% 8.7% 50 76.8% Source: Youth Risk Factor Surveillance System (YRBSS), CDC. YRBSS data are collected every two years. Percentages are as reported on the CDC website and can be found at <http://www.cdc.gov/healthyouth/yrbs.index>. Note that CDC defines overweight among children as at or above the 95th percentile for Body Mass Index (BMI). At Risk for Overweight is defined as at or above the 85th percentile, but below the 95th, for BMI. Physical activity data can be found on state fact sheets at <http://www.cdc.gov/healthyyouth/overweight/facts.htm>. Source: Current National PedNSS Tables, number 6D, available at: <http://www.cdc.gov/pednss/pednss_tables/pdf/national_table6.pdf>. Source: National Survey of Children’s Health, 2003. Overweight and Physical Activity Among Children: A Portrait of States and the Nation 2005, Health Resources and Services Administration, Maternal and Child Health Bureau. 7 Southern states continue to dominate the top 15 most obese states. Mississippi remained the most obese in the nation, while West Virginia replaced Alabama as the second most obese state. States with Highest Obesity Rates Ranking State Percentage of Adult Obesity (Based on 2004-2006 Combined Data, Including Confidence Intervals) 1 Mississippi 30.6% (+/- 0.9) 2 West Virginia 29.8% (+/- 1.0) 3 Alabama 29.4% (+/- 1.2) 4 Louisiana 28.2% (+/- 0.9) 5 (tie) South Carolina 27.8% (+/- 0.7) 5 (tie) Tennessee 27.8% (+/- 1.2) 7 Kentucky 27.5% (+/- 1.0) 8 Arkansas 27.0% (+/- 0.9) 9 (tie) Indiana 26.8% (+/- 0.8) 9 (tie) Michigan 26.8% (+/- 0.8) 9 (tie) Oklahoma 26.8% (+/- 0.8) 12 (tie) Missouri 26.3% (+/- 1.0) 12 (tie) Texas 26.3% (+/- 0.9) 14 Georgia 26.1% (+/- 1.0) 15 Ohio 26.0% (+/- 1.2) Northeastern and Western states dominated those states with the lowest rates of obesity. States With the Lowest Obesity Rates Rank State Percentage of Adult Obesity (Based on 2004-2006 Combined Data, Including Confidence Intervals) 51 Colorado 17.6% (+/- 0.7) 50 Massachusetts 19.8% (+/- 0.7) 49 Vermont 20.0% (+/- 0.6) 47 (tie) Connecticut 20.1% (+/- 0.7) 47 (tie) Hawaii 20.1% (+/- 1.0) 46 Rhode Island 20.5% (+/- 0.9) 45 Montana 20.7% (+/- 0.8) 44 Utah 21.1% (+/- 0.8) 43 Arizona 21.7% (+/- 1.4) 42 New Mexico 22.0% (+/- 0.8) The rate of combined overweight and obese West Virginia at 65.5 percent, Kentucky at adults now exceeds 60 percent in 32 states. 64.9 percent, Alabama at 64.7 percent, and Mississippi has the highest rate of adults North Dakota at 63.8 percent. Colorado has who are either overweight or obese at 66.5 the lowest rate at 54.2 percent. percent. The other top 5 states include 8 Rates and Rankings Methodology This study compares 2003-2005 to 2004-2006 The data are based on telephone surveys con- data in order to stabilize the data by using large ducted by state health departments with assis- enough sample sizes for comparisons between tance from CDC where individuals self-report states and over time based on the advice of their weight and height. Researchers then use officials from the U.S. Centers for Disease these stats to calculate body mass index (BMI) Control and Prevention (CDC). In order for a to determine obesity or overweight. Since state rate to be considered an increase, the the survey is based on self-reporting, experts change must reach a level of what experts con- feel the rates are likely to be slightly underre- sider to be statistically significant (p<0.05) for ported, since individuals tend to underreport the particular sample size of that state. their weight and overreport their height. D.C. is included in the state rankings, since More information about the methodology of CDC funds D.C. to conduct a survey in an the rankings is available in Appendix A. equivalent way to the states. DEFINITIONS OF OBESITY AND OVERWEIGHT Obesity is defined as an excessively high amount of body fat or adipose tissue in relation to lean body mass.7 Overweight refers to increased body weight in relation to height, which is then compared to a standard of acceptable weight.8 Body mass index, or BMI, is a common measure expressing the relationship (or ratio) of weight-to-height. It is a mathematical formula: BMI = (Weight in pounds) x 703 (Height in inches) x (Height in inches) Adults with a BMI of 25 to 29.9 are considered overweight, while individuals with a BMI of 30 or more are considered obese. The National Institutes of Health (NIH) adopted a lower optimal weight threshold in June 1998. Previously, the federal government defined overweight as a BMI of 28 for men and 27 for women. For children and youth, overweight is defined as at or above the 95 percentile of BMI for a person’s age. At risk for being overweight is at or above the 85th percentile, but below the 95th percentile. Overweight is typically used for assessing trends for children and youth rather than obesity. For instance, children and youth are categorized as overweight but not obese in the National Survey of Children’s Health (NSCH), the Youth Risk Behavior Surveillance Survey (YRBSS), and the Pediatric Nutrition Surveillance Survey (PedNSS). There are some issues and disputes surrounding the use of BMI as the primary measure for obesity. ■ For instance, it does not distinguish between fat and muscle, and individuals with a significant amount of lean muscle will have large BMIs, which do not indicate an unhealthy level of fat. ■ Other research has shown that those of African and/or Polynesian ancestry may have less body fat and more lean muscle mass, suggesting higher baseline BMIs for overweight and obesity.9 ■ Research has also found that there may be race or ethnicity issues in BMI measurements. A June 2005 study found that current BMI thresholds “significantly underestimate health risks in many non-Europeans.”10 Asian and Aboriginal groups, despite “healthy” BMIs, had high risk of “weight related health problems.”11 Several years ago, it was suggested to the World Health Organization (WHO) that BMI levels be dropped to 23 and 25 for overweight and obesity, respectively, among Asian populations, but no such changes have occurred. Examining BMI levels is considered useful by a number of researchers for examining trends and patterns of overweight and obesity. However, many experts recommend assessing an individual’s health should include the consideration of other factors beyond BMI, such as waist size, waist-to-hip ratio, blood pressure, cholesterol level, and blood sugar.12 Recently, an expert panel consisting of 15 health organizations recommended that physicians and allied healthcare providers perform, at a minimum, a yearly assessment of weight status in all children, and that this assessment include calculation of height, weight, and BMI for age and plot of those measures on a standard growth chart.13 9 B. CHILDHOOD AND YOUTH OVERWEIGHT RATES The rate of childhood obesity more than 25 million children are now either obese or tripled from 1980 to 2004. Approximately overweight.14 1. Study of 10 to 17 Year Olds According to a 2003-2004 National Survey state. The rates ranged from a low of 8.5 of Children’s Health (NSCH), 14.8 percent percent in Utah to 22.8 percent in D.C. of youth ages 10 to 17 are overweight. This Eight of the 10 states with the highest rates study is based on a survey of parents in each of overweight children are in the South. States With Highest Rates of Overweight 10 to 17 Year Olds Ranking States Percentage of Overweight 10 to 17 Year Olds 1 D.C. 22.8% 2 West Virginia 20.9% 3 Kentucky 20.6% 4 Tennessee 20.0% 5 North Carolina 19.3% 6 Texas 19.1% 7 South Carolina 18.9% 8 Mississippi 17.8% 9 Louisiana 17.2% 10 New Mexico 16.8% 10 Six of the states with the lowest rates of overweight 10 to 17 year olds are in the West. States With Lowest Rates of Overweight 10 to 17 Year Olds Ranking States Percentage of Overweight 10-17 Year Olds 51 Utah 8.5% 50 Wyoming 8.7% 49 Colorado 9.9% 47 (tie) Idaho 10.1% 47 (tie) Minnesota 10.1% 46 Washington 10.8% 44 (tie) Alaska 11.1% 44 (tie) Montana 11.1% 43 Vermont 11.3% 41 (tie) Nebraska 11.9% 41 (tie) Rhode Island 11.9% Methodology of the National Survey of Children’s Health NSCH was fielded using the State and Local Overall, 102,353 interviews were completed Area Integrated Telephone Survey (SLAITS) with a response rate ranging from near 50 per- mechanism, conducted by the National Center cent to near 65 percent, depending on states. for Health Statistics, using the same random Data were weighted according to a variety of digit dial sampling frame as the National socio-economic measures to ensure an accu- Immunization Survey.15 Data were collected rate picture of the population. State level esti- from the parent or guardian “who was most mates have a margin of error of up to 3 per- knowledgeable about the health and health cent, and “small differences between survey care of children under 18 years of age” in the estimates may be due to random survey error,” household from January of 2003 to July of 2004. rather than actual differences in measurement. 2. Study of High School Students According to the Youth Risk Behavior overweight.16 Overweight rates range from Surveillance -- United States 2005 survey of 5.6 percent in Utah to 15.6 percent in high school students conducted every other Kentucky, with a median rate of 12 percent. year by states, 13.1 percent are overweight Thirty-nine states and D.C. participate in and 15.7 percent are at risk for becoming the survey. Overweight Rates of High School Students by Gender Male students 16.0% Female students 10.0% Total average 13.1% Overweight Rates of High School Students by Race Hispanic students 16.8% Black students 16.0% White students 11.8% Total average 13.1% 11 Overweight Rates of High School Students By Gender and Race Hispanic female students 12.1% Hispanic male students 21.3% Black female students 16.1% Black male students 15.9% White female students 8.2% White male students 15.2% Total average 13.1% Total average 13.1% Methodology for the Youth Risk Behavior Surveillance System The Youth Risk Behavior Surveillance System some do not conduct a YRBS (in 2005: CA, (YRBSS) is similar to the BRFSS; it monitors LA, MN, PA, VA, and WA), and some states the prevalence of youth behaviors that influ- that do conduct a YRBS did not achieve a high ence health. The YRBSS includes national, enough overall response rate (in 2005: AK, IL, state, and local Youth Risk Behavior Surveys MS, OR). In some cases, questions asked by (YRBS) of high school students. The data in states may vary. Data are collected every 2 this report are from state and local YRBS that years. TFAH reported percentage of high is reported to CDC. These surveys use a 2 school overweight and 95 percent confidence stage cluster sample design to produce a rep- intervals as listed on CDC’s website resentative sample of 9th through 12th grade <http://www.cdc.gov/healthyyouth/ students in each participating state. Results yrbs.index.htm>. are not available from every state because 3. Study of Low-income Children Ages 2 to 5 A 2005 survey of low-income children ages 2 these children are overweight. Thirty-nine to 5 called the Pediatric Nutrition Surveillance states and D.C. participated in the survey. Survey (PedNSS) found that 14.7 percent of Methodology for the Pediatric Nutrition Surveillance Survey TFAH used PedNSS data as a snapshot of over- by the state, territorial, and tribal governments, weight among low-income pre-school aged and then reported to and published by the children. These data are collected at public CDC. Data are collected yearly and are avail- health clinics across the country, are aggregated able at <http://www.cdc.gov/pednss>. 12 C. PHYSICAL INACTIVITY IN ADULTS The CDC health survey of states includes the of adults report they do not participate in question, “During the past month, did you either level of physical activity.18 engage in any physical activities?” In 2006, Rates of physical inactivity and obesity have more than 22 percent of Americans said they a strong statistical correlation, according to did not engage in any physical activity.17 an analysis performed on behalf of TFAH by The BRFSS survey also asks individuals researchers from the Department of Health whether they participate in either 30 minutes Management and Policy at the University of or more of moderate physical activity 5 or Michigan School of Public Health. For the more days per week, or 20 minutes or more of 2004 to 2006 data, the correlation is 0.52 vigorous physical activity 3 or more days per and the calculated p-value is 0.0001.19 week. The minimum level is comparable to Mississippi, the state with the highest obesity walking 2 miles at 3 to 4 miles per hour. The rate, also had the highest reported rate of phys- 2005 BRFSS survey found that more than half ical inactivity in the country at 31.6 percent. States With the Highest Rates of Physical Inactivity Ranking State Percentage of Adult Physical Obesity Ranking Inactivity (Based on 2004-2006 Combined Data, Including Confidence Intervals) 1 Mississippi 31.6% (+/- 0.9) 1 2 Louisiana 31.3% (+/- 0.9) 4 3 Kentucky 30.6% (+/- 1.0) 7 4 Tennessee 30.5% (+/- 1.1) 5 5 Alabama 29.5% (+/- 1.1) 3 6 Oklahoma 29.4% (+/- 0.8) 9 7 Arkansas 28.6% (+/- 0.9) 8 8 Texas 27.4% (+/- 0.9) 12 9 New Jersey 27.3% (+/- 0.6) 40 10 New York 26.5% (+/- 0.8) 38 Minnesota had the lowest rates of physical inactivity at 15.4 percent. States With the Lowest Rates of Physical Inactivity Ranking State Percentage of Adult Physical Obesity Ranking Inactivity (Based on 2004-2006 Combined Data, Including Confidence Intervals) 51 Minnesota 15.4% (+/- 0.8) 28 50 Washington 17.3% (+/- 0.4) 31 49 Oregon 17.4% (+/- 0.7) 30 48 Colorado 17.8% (+/- 0.7) 51 47 Utah 18.3% (+/- 0.8) 44 46 Vermont 18.4% (+/- 0.6) 49 45 Wisconsin 18.8% (+/- 0.8) 22 44 Hawaii 19.4% (+/- 0.9) 47 43 New Hampshire 19.9% (+/- 0.7) 38 42 Connecticut 20.0% (+/- 0.7) 47 13 D. DIABETES AND HYPERTENSION Obesity and physical inactivity have been states with the highest obesity rates, and 9 of shown to be related to a range of health the 10 states with the highest rates of adult problems, including diabetes and hyperten- hypertension are also in the top 15 states sion. Eight of the 10 states with the highest with the highest rates of obesity. rates of adult diabetes are also in the top 15 1. Diabetes West Virginia had the highest rate of adult Nine of the 10 states with the highest rates diabetes (11.1 percent), while Alaska and of diabetes are in the South. Colorado had the lowest rates (4.8 percent). States With the Highest Rates of Adult Diabetes Ranking State Percentage of Adult Diabetes Obesity Ranking (Based on 2004-2006 Combined Data, Including Confidence Intervals) 1 West Virginia 11.1% (+/- 1.0) 2 2 Mississippi 10.1% (+/- 0.5) 1 3 (tie) South Carolina 9.4% (+/- 0.4) 5 (tie) 3 (tie) Tennessee 9.4% (+/- 0.6) 5 (tie) 5 Alabama 9.3% (+/- 0.6) 3 6 Oklahoma 9.0% (+/- 0.4) 9 7 Louisiana 8.9% (+/- 0.5) 4 8 Kentucky 8.8% (+/- 0.5) 7 9 North Carolina 8.7% (+/- 0.3) 17 10 Florida 8.4% (+/- 0.5) 34 2. Hypertension Mississippi had the highest rate of adult had the lowest at 19.8 percent. Nine of the hypertension at 32.7 percent, while Utah top 10 states are in the South. States with Highest Rates of Adult Hypertension Ranking State Percentage of Adult Hypertension Obesity Ranking (Based on 2001-2005 Combined Data, Including Confidence Intervals) Based on a Survey Conducted Every Other Year 1 Mississippi 32.7% (+/- 1.0) 1 2 West Virginia 32.5% (+/- 1.0) 2 3 Alabama 32.0% (+/- 1.1) 3 4 Tennessee 29.9% (+/- 1.1) 5 (tie) 5 Arkansas 29.8% (+/- 0.9) 8 6 South Carolina 29.7% (+/- 0.8) 5 (tie) 7 Kentucky 29.4% (+/- 0.9) 7 8 Oklahoma 28.8% (+/- 0.8) 9 9 Louisiana 28.6% (+/- 0.9) 4 10 North Carolina 28.4% (+/- 0.8) 17 14 E. OBESITY AND POVERTY Obesity rates also appear to have some rela- higher, many of the states with the lowest tionship with poverty rates in many states poverty rates are among the states with the with some notable exceptions. Eight of the lowest obesity rates. Eight of the states with 10 states with the highest rates of poverty are the highest poverty rates are also in the top in the South, where obesity rates are also 15 states with the highest obesity rates. States with the Highest Poverty Rates Poverty State Percentage of Poverty (Based on Obesity Ranking Ranking 2004-2006 Combined Data with a 90 percent Confidence Interval) 1 (tie) D.C. 18.3% 40 1 (tie) Mississippi 18.3% 1 3 New Mexico 17.5% 42 4 Louisiana 17.4% 4 5 Texas 16.5% 12 6 Alabama 16.2% 3 7 (tie) Arkansas 15.6% 8 7 (tie) Kentucky 15.6% 7 7 (tie) West Virginia 15.6% 2 10 Tennessee 15.0% 5 States with the Lowest Poverty Rates Poverty State Percentage of Poverty (Based on Obesity Ranking Ranking 2004-2006 Combined Data with a 90 percent Confidence Interval) 51 New Hampshire 5.6% 38 50 Minnesota 7.5% 28 49 New Jersey 7.8% 40 48 Vermont 8.0% 49 47 Delaware 8.5% 29 46 Hawaii 8.8% 47 (tie) 45 Connecticut 9.2% 47 (tie) 43 (tie) Maryland 9.4% 25 43 (tie) Utah 9.4% 44 42 Virginia 9.5% 23 15 WHY NATIONAL AND STATE DATA ARE DIFFERENT: 2 SURVEYS The CDC conducts 2 separate information surveys about health statistics. The National Health and Nutrition Examination Survey (NHANES) is designed to study national trends and data. The Behavior Risk Factor Surveillance Survey (BRFSS) studies trends and data in each state. The 2 studies collect information in different ways and, therefore, have different results. The BRFSS numbers are usually lower, because the survey design is based on self-reported information, whereas NHANES data are collected through in person interviews and physician examinations. The number typically cited for the national adult obesity rate is 32 percent using the NHANES data. This number is higher than the estimated percentage for many states, which use BRFSS. NHANES is a nationally representative survey in which data are collected in in person interviews and examinations by physicians. Obesity is calculated using actual height and weight measurements, rather than self-reported data; because of this, the NHANES is often referred to as the ‘gold standard.’ BRFSS is based on state rather than national representation and is a telephone survey where respondents self report their height, weight, and other health information. It is the only source for state level health information. According to CDC, BRFSS is the largest phone sur- vey in the world. Because data show that women are more likely to report that they weigh less than they do while men are more likely to say that they are taller than they are, it is com- monly believed that BRFSS underreports obesity.20 Despite its limitations, BRFSS is the best available source of data on health trends in states and local areas. This taxpayer supported CDC program is the only source that collects state-by- state health information on a regular basis. CDC provides BRFSS information to policymakers, including Congress and state officials, and to the public. CDC presents this information routinely through charts, its Web site, and trend maps. These data provide the opportunity to review trends and patterns. As is done in this report, sometimes CDC presents this data without confidence intervals for the sake of clarity, however, additional information with more detail including sample sizes, confidence intervals, limitations, and data quality is available to the public on CDC’s Web site at www.cdc.gov/brfss/technical_infodata/2004Qualityreport.htm. WHY RANK STATES? TFAH provides state rankings to better inform policymakers and the public about obesity trends in the U.S. The information allows people to gain a better understanding of patterns in rising obesity rates. State rankings also help demonstrate the varying levels of concern and action addressing obesity in different areas of the country. Due to annual variations in the data, and based on advice from CDC officials, TFAH stabilizes the data by combining 3 years. This is similar to how NHANES combines 3 years of data to stabilize any anomalies. 16 State Responsibilities and Policies 2 SECTION I n this section, TFAH examines trends in state legislative actions and policies aimed at obesity reduction. This overview is intended to help inform and begin to evaluate whether efforts are having a positive impact. Each state identifies goals and strategies for plement is available on TFAH’s Web site improving the health of its citizens. www.healthyamericans.org. This section provides an overview and update to previ- States are undertaking a wide range of ous years’ analyses and examines: efforts to try to address the obesity crisis. Since 2003, TFAH has been reviewing state A. Example State and Community Efforts; policies to help inform and evaluate the B. School-Focused Obesity Legislation; impact of these efforts. For this year’s C. Community-Focused Obesity Legislation report, TFAH produced a Supplement to F and Federal Grants to States; and as in Fat: Obesity-Related Legislation Action D. Examples of State Obesity Medicaid in States, which provides greater detail Health Care Benefits. about specific legislation in states. The sup- A. EXAMPLES OF COMMUNITY EFFORTS IN STATES State governments are supporting varied Center for Best Practices has launched a approaches to obesity, ranging from public Healthy States Grant Program as part of education campaigns to issuing public chal- its Healthy America Initiative. The pro- lenges to get in better shape to increasing gram has provided 13 states with up to parks and recreation development. In addi- $100,000 in funding for community or tion, a number of state governments are lead- worksite wellness efforts.22 NGA has also ing by example by supporting healthy living launched a Healthy Kids, Healthy initiatives for state government employees.21 America Program that will award up to State governments are often both the largest $110,000 for one year each to 10 states employer and largest provider of health with programs focusing on preventing insurance in their states, and can help serve childhood obesity through policy and as examples to other employers within a environmental change in the future.23 state. Also, many states are developing pub- The types of efforts supported by the lic-private partnerships as a major compo- Healthy States Programs provide examples nent of obesity prevention initiatives. of the types of state obesity prevention and To help support state efforts, the control activities. National Governors Association (NGA) 17 NATIONAL GOVERNORS ASSOCIATION (NGA) CENTER FOR BEST PRACTICES LAUNCHES HEALTHY STATES GRANT PROGRAM Colorado: Colorado seeks to transform the Denver metro area into America’s Healthiest Community, by building on existing programs, such as the Physical Activity and Nutrition Program and the Denver Metro Health and Wellness Commission, to encourage worksite wellness. The program will provide training and resources, as well as develop metrics for measuring the return on investment of worksite wellness. Colorado officials hope to pilot the program in at least 2 Denver area worksites.24 Connecticut: Connecticut’s program focuses on state employees (the state’s largest workforce), by creating an infrastructure for a State Employee Worksite Wellness Initiative. The program will include coordinated data management and an evaluation system that links chronic disease risk reduction data to health care expenditures and human resource data. They will also undertake the research and resource development projects necessary to broaden the program.25 Georgia: Georgia’s grant will go toward the Live Healthy Georgia Learning Laboratory Project that is designed to promote active, hands-on learning, to motivate healthy lifestyle behaviors and attitudes. It will focus on the school worksite in order to promote school- based employees as healthy role models and develop a school community culture that sup- ports health. The program is part of a public-private partnership with United Healthcare and will be piloted in 2 communities chosen from Live Healthy Georgia target areas that include Albany, Atlanta, Gainesville, Macon, Rome, and Savannah.26 Iowa: The NGA grant supports the Building Capacity for Healthier Communities project which seeks to expand current efforts in 3 target communities to create a community model that can be replicated for developing fresh food sources, improving walkability of communities and improving planning for community health. The project will create and implement walka- bility assessments and community action plans.27 Maine: Maine’s grant will develop and implement a worksite wellness program specifically for small employers, which in Maine is often around 3 people per firm. The project will develop a toolkit and resources that may include health risk assessments, incentives for use of preven- tive care, and tobacco control. It will also recruit pilot companies, and then implement and assess employee health and the program itself.28 Michigan: This NGA grant will help Michigan engage private sector employers in implement- ing worksite wellness action plans. It builds on existing state programs, drawing 25 companies (with 50 employees or more) from Gov. Jennifer Graholm’s (D-MI) Cities of Promise initia- tive and linking them with the Michigan Steps Up program. Participating companies will com- plete health risk assessments provided by the state, draft healthy workplace action plans, and make at least one designated improvement at their site. Mini-grants will be provided to com- panies and both the state and NGA will provide technical assistance. It is the state’s hope that they will be able to demonstrate that healthy workplaces are cost effective, providing an incentive for the program to expand.29 Minnesota: Minnesota will create a Workplace Wellness Toolkit that will be piloted with groups of employees from the public and private sectors. Once this is completed, Gov. Tim Pawlenty (R- MN) will host a summit to promote the toolkit statewide. The tools will focus on healthy eating and active living strategies that are effective and already being used throughout the state.30 Nebraska: The Nebraska Employee Wellness (NEW) for Life will build on an ongoing well- ness program to improve the health of state employees and reduce the cost of health insur- ance. New funding will allow the state to provide metabolic screenings for state employees and continue to have a personal trainer/nutritionist see employees in Lincoln. Additionally, work is under way to build walking paths around state buildings and food in employee cafete- rias is being reworked with the goal of at least 60 percent of food defined as nutritious.31 18 Oklahoma: Oklahoma seeks to promote a culture change from unhealthy to healthier behav- iors and lifestyles, as it is the only state where age adjusted death rates have increased over the past 15 years. NGA funding will support training curriculum for the Make It Your Business program, as well as a statewide outreach campaign about the curriculum.32 South Dakota: The NGA funding will support South Dakota’s Healthy States project to allow the state Department of Health in partnership with the South Dakota State University Cooperative Extension Services (DOH/CES) to specifically target technical assistance to rural worksites in underserved and minority areas. Additionally, 10 new worksites will be chosen for wellness projects (including one pilot project with an American Indian Casino) and mini grants will be available to those companies already making changes. The state will develop a data collection system to gather data from individual sites and it will also create an online assessment tool for the sites to use.33 Utah: Utah’s program seeks to increase opportunities for Utahns in low-income neighbor- hoods to participate in gardening to improve health. Education about the benefits of garden- ing, both as physical activity and as a source of nutritious food, will be provided to the public through community partnerships and the creation of a new policy team. Funding will also be provided to facilitate at least 10 new or expand existing community gardens. Finally, sustain- ability and long term accountability will also be a part of the gardens project.34 Washington: NGA funding will support the Washington Wellness Works program which aims to make state employees, dependents, and retirees healthier and more productive while thwarting rising health care costs and producing a positive return on investment. Goals for 2007 include communicating, engaging, and measuring the target audience to include the com- pletion of health risk assessments and behavior change around physical activity, food selection, preventive health care, and tobacco. Much of this will be an online interface, and the state is also working on an evaluation tool with the Universities of Washington and Michigan.35 Wisconsin: The Healthier Wisconsin Worksite initiative seeks to create healthy work envi- ronments that support and promote healthy eating, daily physical activity and a healthy weight. Three key components to achieve this include (1) drafting an action plan to imple- ment health risk assessments for state employees; (2) forming 10 community-business part- nerships to implement worksite wellness plans; and (3) holding the Governor’s Worksite Wellness Summit to increase awareness of the program.36 19 NEW YORK CITY: POSTING CALORIES AND BANNING TRANS FATS IN RESTAURANTS In addition to state and federal governments, local governments across the country are initiat- ing obesity-related health promotion efforts. New York City has taken strong measures by mandating restaurants to provide increased nutrition and calorie information to patrons and instituting a ban on trans fats. In December of 2006, the New York City Board of Health mandated “prominent display” of calorie content in “all food service establishments that have standardized preparation and portion sizes and that make calorie information publicly available on or after March 1, 2007 (e.g., on Web sites, in brochures, or on posters, food wrappers or tray lines) ... on menus and menus boards.”37 The caloric labeling issue has been complex since the regulation only applies to establishments that already had caloric information publicly posted as of March 1, 2007. Several establish- ments, such as Wendy’s and Quiznos, actually stopped providing such information to avoid the mandate. Implementation of the regulation has been delayed for 3 months (from July to October) because of a court challenge.38 The Board of Health also passed a ban on all but trace amounts of trans fats used in city restaurants, making New York City the first municipality in the country to institute such a ban. “Beginning July 1, 2007, you may not use partially hydrogenated vegetable oils, shortenings, or margarines for frying, pan-frying (sautéing), or grilling, or as a spread, unless you have product labels or other documents from a manufacturer showing that these ingredients contain less than 0.5 grams of trans fat per serving. You may continue to use trans fat-containing oils and shortenings for deep frying cake batter and yeast dough until July 1, 2008, when the regulation takes full effect.” “Beginning July 1, 2008, if you store, use, or serve any food item containing partially hydro- genated vegetable oil, shortening or margarine, it must contain less than 0.5 grams of trans fat per serving. This rule applies even to oils or shortenings used to deep fry cake batter and yeast dough. The regulation does not apply to food served in the manufacturer’s original, sealed packaging, such as a package of crackers of a bag of potato chips.” The Board of Health also launched a “Trans Fat Help Center,” which aims to “assist restau- rants in switching from artificial trans fat to healthier oils while maintaining the same taste and texture of food.”39 The Web site also defines the new guidelines for restaurateurs.40 B. SCHOOL-FOCUSED OBESITY LEGISLATION Since 2003, TFAH has tracked state legislation or pass legislation that affect schools, but that impacts nutrition and physical education the localities typically have discretion in in schools. This section provides an updated deciding if they will follow them. States may summary of legislative activities. Additional try to create incentives for following poli- detail about the legislation can be found in the cies, such as attaching compliance rules to Supplement to F as in Fat on TFAH’s Web site. state funding. However, school districts may choose to ignore state policies. School-based programs have been shown to have the potential to yield positive results in Emerging school-based efforts have focused preventing and reducing obesity.41 Children on improving the quality of food sold in spend large portions of time at school, and in schools, limiting sales of less nutritious before and afterschool programs, and often foods, improving physical education and consume 2 meals and snacks in these settings. health education, and encouraging increased physical activity either within the The more than 14,000 school districts in the school day or through extracurricular pur- United States have primary jurisdiction for suits. Some communities have also under- setting policies. States can establish policies 20 taken more comprehensive programs, such state and the Child and Adolescent Trial for as a statewide initiative in Arkansas measur- Cardiovascular Health (CATCH) program ing the BMIs of students throughout the involving 96 schools in 4 states. OBESITY-RELATED STANDARDS IN SCHOOLS -- 2007 Nutritional Nutritional Limited Physical BMI or Non-Invasive Health Receives Standards for Standards for Access to Education Health Screening Education CDC School School Meals Competitive Competitive Requirements Information for Diabetes Requirements Health Grants Foods Foods Collected Alabama ✓ ✓ ✓ ✓ ✓ Alaska ✓ ✓ Arizona ✓ ✓ ✓ ✓ ✓ Arkansas ✓ ✓ ✓ ✓ ✓ ✓ ✓ California ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Colorado ✓ ✓ ✓ ✓ Connecticut ✓ ✓ ✓ ✓ ✓ Delaware ✓ ✓ ✓ DC ✓ ✓ Florida ✓ ✓ ✓ ✓ ✓ Georgia ✓ ✓ ✓ Hawaii ✓ ✓ ✓ ✓ ✓ Idaho ✓ ✓ Illinois ✓ ✓ ✓ ✓ ✓ ✓ Indiana ✓ ✓ ✓ ✓ ✓ Iowa ✓ ✓ ✓ Kansas ✓ ✓ ✓ ✓ Kentucky ✓ ✓ ✓ ✓ ✓ ✓ Louisiana ✓ ✓ ✓ ✓ ✓ Maine ✓ ✓ ✓ ✓ ✓ ✓ Maryland ✓ ✓ ✓ ✓ Massachusetts ✓ ✓ ✓ ✓ Michigan ✓ ✓ ✓ Minnesota ✓ ✓ Mississippi ✓ ✓ ✓ Missouri ✓ ✓ ✓ Montana ✓ ✓ Nebraska ✓ ✓ ✓ Nevada ✓ ✓ ✓ ✓ ✓ New Hampshire ✓ ✓ New Jersey ✓ ✓ ✓ ✓ ✓ New Mexico ✓ ✓ ✓ ✓ New York ✓ ✓ ✓ ✓ ✓ North Carolina ✓ ✓ ✓ ✓ ✓ ✓ North Dakota ✓ ✓ ✓ Ohio ✓ ✓ Oklahoma ✓ ✓ ✓ ✓ Oregon ✓ ✓ ✓ Pennsylvania ✓ ✓ ✓ Rhode Island ✓ ✓ ✓ ✓ ✓ South Carolina ✓ ✓ ✓ ✓ ✓ ✓ ✓ South Dakota ✓ ✓ ✓ ✓ Tennessee ✓ ✓ ✓ ✓ ✓ ✓ Texas ✓ ✓ ✓ ✓ ✓ Utah ✓ ✓ Vermont ✓ ✓ ✓ ✓ Virginia ✓ ✓ Washington ✓ ✓ ✓ West Virginia ✓ ✓ ✓ ✓ ✓ ✓ Wisconsin ✓ ✓ ✓ Wyoming ✓ ✓ # of States 17 22 26 50 + D.C. 16 2 48 + D.C. 23 Please Note: Checkmarks in chart above that are in red type represent new laws passed in 2006 or 2007. 21 OBESITY RELATED STATE INITIATIVES -- 2007 Has a CDC State-Based Receives Has Limited Has Snack Taxes Nutrition & Physical STEPS Grant Liability Laws Activity Program Alabama ✓ Alaska Arizona ✓ ✓ ✓ Arkansas ✓ ✓ California ✓ Colorado ✓ ✓ ✓ Connecticut Delaware DC ✓ Florida ✓ ✓ Georgia ✓ ✓ Hawaii Idaho ✓ Illinois ✓ ✓ ✓ Indiana ✓ ✓ Iowa ✓ Kansas ✓ Kentucky ✓ ✓ ✓ Louisiana ✓ Maine ✓ ✓ ✓ Maryland ✓ Massachusetts ✓ Michigan ✓ ✓ Minnesota ✓ ✓ Mississippi Missouri ✓ ✓ ✓ Montana ✓ Nebraska Nevada New Hampshire ✓ New Jersey ✓ New Mexico ✓ New York ✓ ✓ ✓ North Carolina ✓ North Dakota ✓ ✓ Ohio ✓ Oklahoma ✓ Oregon ✓ ✓ Pennsylvania ✓ ✓ Rhode Island ✓ ✓ South Carolina ✓ South Dakota ✓ ✓ Tennessee ✓ ✓ Texas ✓ ✓ ✓ Utah ✓ Vermont ✓ Virginia ✓ Washington ✓ ✓ ✓ ✓ West Virginia ✓ ✓ Wisconsin ✓ ✓ Wyoming ✓ # of States 17 + D.C. 28 7 24 22 ■ Seventeen states set nutritional standards for school lunches, breakfasts, and snacks that are stricter than existing U.S. Department of Agriculture (USDA) requirements. The 17 states include: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Kentucky, Nevada, New Jersey, North Carolina, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, and Vermont. States that implemented new regulations in 2006 and 2007 include: ■ Colorado created the Fresh Fruits and Vegetables Pilot Program for the 2006-07 and 2007-08 school years (SB 127). ■ Connecticut established a farm-to-school program which promotes the sale of Connecticut-grown farm products to schools (HB 5847). ■ New Jersey established prepaid school lunch programs so parents can prepay for more nutritious lunches served in school cafeterias (AB 370). ■ Oklahoma required the State Department of Education to make available to schools infor- mation and technical assistance in establishing healthy school nutrition environments (SB 1459). The state also created the Oklahoma Farm to School Program to provide schools with fresh and minimally processed farm commodities (HB 2655). ■ South Carolina’s State Board of Education implemented nutrition standards for school food service meals in elementary schools (R43-168). Effective, June 23, 2006, elementary schools must offer a low-fat meal choice (30 percent or less of calories from fat) at every meal; provide low-fat and nonfat salad dressings; provide information on calories, percent- ages of fat, and serving sizes of school meal items to help children select appropriate food portions; offer a minimum of 4 choices of fruits and vegetables daily, including fresh fruits and vegetables in season; and offer whole-grain foods in all programs in elementary schools, whenever possible, to meet bread and cereal requirements. ■ Vermont created a local foods mini-grant program to encourage local school districts to serve food to Vermont students that is as fresh and nutritious as possible (HB 465). ■ Twenty-two states have nutritional standards for competitive foods sold a la carte, in vending machines, in school stores, or in bake sales in schools. The 22 include: Alabama, Arizona, Arkansas, California, Connecticut, Hawaii, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Nevada, New Jersey, New Mexico, North Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee, Texas, and West Virginia. States that implemented new standards in 2006 and 2007 include: ■ Arizona’s Department of Education released the final Arizona Nutrition Standards in January 2006. They officially became effective on July 1, 2006 (ARS 15-242). Foods and beverages sold in vending machines, snack bars, a la carte, fundraisers, and at school events during the normal school day must meet the following standards: • FOODS: 35 percent or less of total calories from fat; 10 percent or less of total calories from saturated and trans fatty acids (combined); no more than 35 percent total sugar by weight; must contain at least 1 gram of fiber; maximum 400 calories per serving and 800 mg of sodium for entrée items sold as a la carte; and maximum 300 calories per serving and 600 mg of sodium for all other snack items. Finally, all deep-fat fried chips and crack- ers and deep-fat fried final preparation methods are prohibited. • BEVERAGES: water may contain natural or non-caloric sweeteners but cannot contain caffeine or caffeine derivative; juice must contain 100 percent fruit and/or vegetable juice for elementary schools and must contain no less than 50 percent fruit and/or vegetable juice, no sugar added, with nutrient values equal to 100 percent juice for middle and junior high schools; fruit smooth- ies (yogurt or ice based), which cannot exceed 400 calories, must contain 100 percent fruit juice for elementary schools and must contain no less than 50 percent fruit juice for middle and junior high schools; allowable milk and milk alternative products include fat free, low fat (1 per- cent milk fat), and reduced fat milk (2 percent fat milk), reduced fat enriched rice, nut or soy milk, and flavored milk that contains no more than 4 grams of sugar per ounce; and sports drinks and electrolyte-replacement drinks may only be served in middle and junior high schools. 23 ■ Connecticut restricted the types of beverages sold in schools to: • Milk (must contain no artificial sweeteners and no more than 4 grams of sugar per ounce); • Nondairy milks, such as soy or rice milk (must contain no artificial sweeteners, no more than 4 grams of sugar per ounce, no more than 35 percent of calories from fat per por- tion, and no more than 10 percent of calories from saturated fat per portion); • 100 percent fruit and vegetable juices (must contain no added sugars, sweeteners or arti- ficial sweeteners); and • Water (must contain no added sugars, sweeteners, artificial sweeteners, or caffeine). • Portion sizes of the beverages (other than water) must not exceed 12 ounces (SB 373). ■ Illinois restricted the types of beverages sold to students in 8th grade and below during the regular school day (23 Illinois Administrative Code Ch. 1, Section 305.15). Beverages shall include only (1) flavored, or plain whole, reduced fat (2 percent), low-fat (1 percent), or nonfat milk, (2) reduced fat and alternative dairy beverages (i.e., rice, nut or soy milk or any other USDA-approved alternative beverage), (3) fruit and vegetable drinks containing 50 percent or more juice, (4) non-flavored, non-carbonated water, (5) yogurt or ice based fruit smoothie that contains less than 400 calories and no added sugars and is made from fresh or frozen fruit or fruit drinks containing at least 50 percent fruit juice, and (6) any beverage exempted from USDA’s list of Foods of Minimal Nutritional Value. Illinois also established guidelines for food sold to students outside of food service areas or within food service areas other than during meal periods. These foods can include only the following: (1) nuts, seeds, nut butters, eggs, cheese packaged for individual sale, fruits or non-fried vegetables, or low-fat yogurt products or (2) any food item whose total calories from fat do not exceed 35 percent, calories from saturated fat do not exceed 10 percent, total amount of sugar by weight does not exceed 35 percent and calories do not exceed 200 (23 Illinois Administrative Code Ch. 1, Section 305.15). ■ Indiana Code (IC 20-26-9-19) requires that at least 50 percent of the food items available for sale at a school or on school grounds that are not part of the federal school lunch or breakfast program must qualify as better choice foods and beverages. Better choice beverages include: fruit or vegetable based drinks that contain at least 50 percent real fruit juice or vegetable juice and do not contain additional caloric sweeteners; water and seltzer water than do not contain additional caloric sweetners; low fat and fat free milk, including chocolate milk, soy milk, rice milk, and other similar dairy and nondairy calcium fortified milks; and isotonic beverages. Soft drinks, punch, iced tea and coffee do not qualify as better choice beverages. Better choice food items must meet the following standards: not more than 30 percent of their total calories from fat; not more than 10 percent of their total calories from saturated and trans fat; and not more than 35 percent of their weight is from sugars that do not occur naturally in fruits, vegetables, or dairy products. A food item may not exceed the following portion limits if it contains more than 210 calories: 1.75 ounces for chips, crackers, popcorn, cereal, trail mixes, nuts, seeds, dried fruits, and jerky; cookies and cereal bars, 2 ounces; bakery items, 3 ounces; frozen desserts (including ice cream), 3 fluid ounces; and nonfrozen yogurt, 8 ounces. A beverage item may not exceed 20 ounces. 24 ■ Kentucky administrative regulation (720 KAR 6:090) requires that during the period of time beginning 30 minutes after the last lunch period until the end of the last instructional period, food and beverages offered for sale through a vending machine, school store, canteen, or fundraiser on school property must meet the following nutritional standards (effective February 3, 2006): • Beverages must be fluid unflavored or flavored milk that is no more than one percent milk fat; plain or flavored, noncaloric, noncarbonated water; 100 percent fruit or veg- etable juice or any combination of both totaling 100 percent; and any other beverage that contains no more than 10 grams of sugar per serving (limit does not apply to juices con- taining 100 percent fruit and/or vegetable juice). Except for water, beverages shall not exceed 17 ounces in elementary schools and 20 ounces in middle or high schools. • Food calories from fat shall not exceed 30 percent (excluding reduced fat cheese, nuts, seeds, and nut butters); calories from saturated fat shall not exceed 10 percent; calories from sugar shall not exceed 32 percent by weight; chips, cereals, crackers, baked goods and other snack items shall not contain more than 300 milligrams of sodium per serving; pastas, meats and soups shall not contain more than 450 milligrams of sodium per serving; and pizzas, sandwiches and main dishes shall not contain more than 600 milligrams of sodium per serving. Portion sizes for chips, crackers, popcorn, cereal, trail mix, nuts, seeds, or jerky shall not exceed two ounces; portion sizes for cookies shall not exceed one ounce; portion sizes for cereal bars, granola bars, and bak- ery-type items shall not exceed two ounces; portion sizes for nonfrozen yogurt shall not exceed eight ounces; and portion sizes for frozen dessert items shall not exceed four ounces. ■ New Jersey passed nutritional standards for snacks and beverages sold in schools. Snacks must contain no more than eight grams of total fat per serving (with the exception of nuts and seeds) and no more than 2 grams of saturated fat per serving. All beverages (except milk containing 2 percent or less fat or water) must not exceed 12 ounces and whole milk must not exceed 8 ounces. In elementary schools, beverages shall be limited to milk, water or 100 percent fruit or vegetable juices. In middle and high schools, at least 60 percent of all beverages offered (other than milk or water) must be 100 percent fruit or vegetable juice. In addition, no more than 40 percent of all ice cream and frozen desserts shall exceed the above standards for sugar, fat and saturated fat. All schools shall reduce the pur- chase of any products containing trans fats beginning September 1, 2007 (SB 1218). ■ New Mexico administrative code (6.12.5) establishes the following requirements for com- petitive foods and beverages sold in vending machines and a la carte to students in elemen- tary, middle and high schools: • ELEMENTARY SCHOOLS: Beverages shall only include milk with a fat content of 2 percent or less, soy milk, and water. • MIDDLE SCHOOLS: Beverages shall only include milk with a fat content of 2 percent or less, soy milk, water, and 100 percent fruit juice that has no added sweeteners and no more than 125 calories per container and serving size not to exceed 20 ounces. Food products other than nuts, seeds, cheese, yogurt, and fruit sold in vending machines shall contain no more than 200 calories, no more than 8 grams of fat, no more than 2 grams of fat from saturated and trans-fats, and no more than 15 grams of sugar per package or serving. • HIGH SCHOOLS: Beverages shall only include milk with a fat content of 2 percent or less, soy milk, water, and juice that is at least 50 percent fruit and that has no added sweeteners and a serving size not to exceed 20 ounces. Beverages sold in vending machines to high school students after the last lunch period is completed shall only include carbonated soft drinks that are both sugar free and caffeine free, non-carbonated flavored water with no added sweeteners, and sports drinks. Food products other than nuts, seeds, cheese, yogurt, and fruit sold in vending machines shall contain no more than 200 calories, no more than 8 grams of fat, no more than 2 grams of fat from saturated and trans-fats, and no more than 15 grams of sugar per package or serving. • Food products other than nuts, seeds, cheese, yogurt, and fruit sold in a la carte offerings in elementary, middle and high schools shall contain no more than 400 calories, no more than 16 grams of fat (of which no more than 2 grams can come from saturated and trans fats combined), and no more than 30 grams of total sugar per package or serving. 25 ■ Rhode Island statute 16-21-29 reuquires all elementary, middle, and junior high schools to offer healthier beverages and snacks by January 1, 2007 and January 1, 2008, respectively. Healthier beverages are defined as: water, including carbonated water, flavored or sweetened with 100 percent fruit juice and containing no added sweetener; two percent fat milk, one percent fat milk, nonfat milk, and dairy alternatives, such as fortified soy beverages, plain or flavored, with a sugar content of not more than four grams per ounce; one hundred percent fruit juice or fruit based drinks that are composed of no less than 50 percent fruit juice and have no added sweetener; and vegetable-based drinks that are composed of no less than 50 percent vegetable juice and have no added sweetener. Healthier snacks are defined as: indi- vidually sold portions of nuts, nut butters, seeds, eggs, and cheese packaged for individual sale, fruit, vegetables that have not been deep fried, and legumes; individually sold portions of low fat yogurt with not more than four grams of total carbohydrates (including both naturally occurring and added sugars) per ounce and reduced fat or low fat cheese packaged for indi- vidual sale; and individually sold enriched or fortified grain or grain products or whole grain foods that contain no more than 30 percent calories from fat, no more than 10 percent total calories from saturated fat, and no more than seven grams of total sugar per ounce. ■ South Carolina’s State Board of Education implemented nutrition standards for competi- tive foods in elementary schools (R43-168). Effective June 23, 2006, elementary schools must ensure that one serving of snacks, sweets, and side dishes has no more than 30 per- cent of calories from fat, less than 10 percent of calories from saturated fat, no more than 1 percent of calories from trans fatty acids, and no more than 35 percent of added sugar by weight (nuts, seeds and some cheeses are exceptions). Single-serving food items must be limited to the following portion sizes: 1.25 ounces for snacks; 2 ounces for cookes or cere- al bars; 3 ounces for other bakery items; 4 ounces for frozen desserts, including ice cream; 8 ounces for yogurt (non frozen); and 1/2 cup for fried potatoes or other fried vegetables. Beverages, except water or nonfat, low-fat, or reduced-fat milk, cannot exceed 12 ounces. Low-fat, nonfat, and 2 percent milk, water, and 100 percent juices that do not contain added sugars and sweeteners must be available to all students. ■ Twenty-six states limit when and where competitive foods may be sold beyond federal requirements. The 26 states include: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Mississippi, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Oklahoma, South Carolina, Texas, and West Virginia. States that implemented new restrictions in 2006 and 2007 include: ■ Illinois Administrative Code (23 IAC Ch. 1, Section 305.15) requires all schools partici- pating in the free lunch and breakfast programs in which grades five and below are operat- ing to prohibit the sale of all confections, candy, and potato chips to students during meal periods (effective the first day of the 2006-2007 school year). ■ Indiana Administrative Code (IC 20-26-9-19) states that a vending machine at an elemen- tary school that dispenses food or beverage items may not be accessible to students. ■ Nebraska’s Department of Education clarified its Competitive Food Policy for schools partici- pating in the National School Lunch Program in June 2006.42 According to the clarification, no food or beverages can be sold to children anywhere on school premises beginning one half hour before breakfast and/or lunch service until one half hour after meal service unless all proceeds earned during these time periods go to the school nutrition program. No foods of minimal nutritional value (FMNV) can be sold in the food service areas beginning one half hour before breakfast and/or lunch service until one half hour after meal service under any circumstances. 26 ■ New Jersey recently passed new legislation restricting the timing and location of the sale of competitive foods in schools. The act declares that as of September 2007, the following items cannot be served, sold, or given away as a free promotion anywhere on school property at any time before the end of the school day (including items served in reimbursable After School Snack Program): foods of minimal nutritional value, as defined by the U.S. Department of Agriculture; all food and beverage items listing sugar, in any form, as the first ingredient; and all forms of candy as defined by the New Jersey Department of Agriculture. Food and beverages served during special school celebrations or during curriculum related activities are exempt from the provisions, with the exception of foods of minimal nutritional value (SB 1218). ■ New Mexico administrative code (6.12.5) restricts carbonated beverages and competitive food products from being sold in vending machines to students in elementary schools. Carbonated beverages also shall not be sold in vending machines to students in middle schools. Food products other than nuts, seeds, cheese, yogurt, and fruit sold in vending machines in middle schools shall only be sold after the last lunch period is completed. Carbonated beverages or soft drinks, non-carbonated flavored water and sports drinks shall not be sold in a la carte offerings in elementary, middle and high schools. ■ South Carolina’s State Board of Education restricted access to competitive foods in ele- mentary schools (R43-168). Effective June 23, 2006, elementary schools cannot sell or serve the following beverages to students until after the last regularly scheduled class: soda, soft drinks, sports drinks, punches, iced teas and coffees, and fruit-based drinks that contain less than 100 percent real fruit juice or that contain added sweeteners. ■ Every state has some form of requirements for physical education for students, however, these requirements are often limited or not enforced and many of the programs are inadequate with respect to quality. See Section 4: Promoting Physical Activity as a Strategy to Improve Health for a more detailed discussion about physical education and activity in schools and in before and afterschool programs. ■ Only 2 states -- Colorado and Oklahoma, -- do not require schools to provide health education. ■ Twelve states -- Arkansas, California, Delaware, Florida, Illinois, Kansas, Maine, Missouri, New York, Pennsylvania, Tennessee, and West Virginia -- have passed legis- lation enabling schools to test students’ BMI levels as either part of health examina- tions or physical education activities. In addition, Iowa requires the measurement, report- ing and tracking of height and weight under an elementary school pilot program; Louisiana requires the assessment of changes in the weight status of students participating in a three-year nutrition and physical activity pilot program; Massachusetts mandates the annual measure- ment of each student’s weight and height; and South Carolina requires fitness reports of stu- dents to be sent home to parents in the 5th and 8th grades and in high school. States that recently passed new BMI or obesity-related screening legislation, most including provisions regarding communicating with parents and guardians and maintaining privacy, include: ■ Arkansas passed legislation stating that every school district shall, beginning with kinder- garten and then in even numbered grades, require schools to include as a part of a student health report to parents a BMI percentile by age for each student. Permits any parent to refuse to have their child’s BMI assessed and reported. Students in grades eleven through twelve are exempt from any policy or requirement of a public school or the state for meas- uring or reporting BMI (HB 1173). ■ California code requires individual student BMI to be reported to parents via confidential letter as part of a non-invasive diabetes screening pilot program for 7th and 8th graders. 27 ■ Delaware passed legislation requiring the Department of Education to develop a regula- tion for schools to assess the physical fitness of each student at least once at the elemen- tary, middle and high school level. The assessment results are to be provided to parents or guardians. Includes measuring BMI as part of the testing in some local school districts. This is currently a pilot program (HB 372). ■ Florida statute requires school health services programs to administer growth and devel- opment screening for students. BMI is encouraged as part of these screenings for all stu- dents in 1st, 3rd, 6th and, optionally, 9th grades. ■ Iowa legislation (SB 2124) establishes a pilot grant program (in six communities) to increase the physical activity and fruit and vegetable consumption of targeted youth of ele- mentary school age. Grant requirements include the measurement, reporting, and tracking of the height and weight of students in participating elementary schools. ■ Missouri law requires the department of elementary and secondary education to establish a “Model School Wellness Program,” which will create school-based pilot programs (for grades K-5) that will promote healthy eating and physical activity. Following completion of the 2005- 06 school year, the law requires the department to evaluate the effectiveness of the program through various measures, including changes in student BMI (Chapter 167, Section 167.229). ■ South Carolina passed new legislation (HB 3499) that requires all K-12 schools in the state to participate in the South Carolina Physical Education Assessment and requires that an individual’s fitness status must be reported to his parent or guardian during a student’s fifth grade, eighth grade, and high school physical education courses. ■ West Virginia passed new legislation that changes the state’s previous BMI measurement policy. The new law requires BMI testing for only a scientifically drawn sample of students. Requires the data to be collected and reported in a manner that protects student confiden- tiality (SB 785). ■ Two states have enacted legislation requiring screening students for risk of type 2 diabetes -- California and Illinois. ■ Only 23 states received funds from the CDC to support school-based, obesity- reduction initiatives in 2006. SCHOOL HEALTH PROFILES States and local education and/or health departments conduct a bi-annual survey to monitor school health education requirements and content; physical education requirements; asthma management activities; food service; competitive foods practices and policies; family and com- munity involvement in school health programs; school health policies related to human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) prevention, tobacco-use prevention, violence prevention, and physical activity.43 The information about the survey and statistics from CDC’s YRBS can be found in School Health Profiles available on CDC’s Web site: http://www.cdc.gov/healthyyouth/profiles/index.htm. The 2006 profiles were not yet available as of July 2007. In 2004, 8 states did not administer the survey (Florida, Georgia, Mississippi, New Mexico, New Jersey, Nevada, Rhode Island, and Vermont), but in an additional 14 states, the responding sample size was not large enough to draw statewide conclusions, so profiles are available for 28 states. 28 FOOD IN SCHOOLS Food is usually available for sale in schools either through meal programs or through vending machines, snack shops, school stores, or bake sales. Meal programs: School lunch, breakfast, and afterschool snack programs are offered by state school systems in coordination with the U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS). The USDA subsidizes states if their meal programs meet national nutri- tion guidelines and offer “free or reduced cost” meals to children from low-income households. ■ Seventeen states set nutritional standards for school lunches, breakfasts, and snacks that are more strict than existing U.S. Department of Agriculture (USDA) requirements. Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Kentucky, Nevada, New Jersey, North Carolina, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, and Vermont. The 2004 Child Nutrition and Women, Infant, and Children (WIC) Reauthorization Act requires all local educations agencies receiving federal dollars for school meals to establish local wellness policies. “Competitive” foods: Food sold from snack shops, school stores, vending machines and through á la carte lines in cafeterias are considered “competitive” foods. The term denotes that the sale of these foods is in “competition” with the standard meal programs. Moreover, the sale of most com- petitive foods is not required to meet the USDA nutrition guidelines. The standards for these sales are set by states or local school systems.44 States and localities can make decisions both about the nutritional requirements as well as limits on when and where competitive foods may be sold. According to a March 2004 Government Accountability Office (GAO) report, federal regula- tions restrict only a small subset of competitive foods from being sold during meal times in cafeterias.45 These include “foods of minimal nutritional value (FMNV),” such as candy, water ices, chewing gum, and soft drinks. Other competitive foods which are not regulated by the federal government include fruit, vegetables, hamburgers, potato chips, French fries, pizza, and pretzels. However, these federal regulations do not prohibit selling these minimally nutri- tional value foods outside of the cafeteria areas at any time during the day. ■ Twenty-two states have nutritional standards for competitive foods in schools. Alabama, Arizona, Arkansas, California, Connecticut, Hawaii, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Nevada, New Jersey, New Mexico, North Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee, Texas, and West Virginia. ■ Twenty-six states limit when and where competitive foods may be sold beyond federal requirements. Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Mississippi, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Oklahoma, South Carolina, Texas, and West Virginia. KEY CONCERNS ABOUT FOOD IN SCHOOLS ■ Substandard Nutrition Requirements for Meals: USDA meal requirements are focused on states and localities meeting minimum nutrition guidelines. Reports by USDA, GAO and independent researchers have all found the nutrition in school lunches to be “substandard.”46 ■ Unmonitored Contracting for School Lunches: In December 2004 the Food and Nutrition Service (FNS), via new proposed regulations, advised “school food personnel to be more careful about how they contract for the food that will be served to children.”47 ■ Competitive Food Polices Do Not Always Balance Revenue and Health: Many schools receive revenue from the sale of competitive foods. Money from food sales are often used to pay for special activities or items not covered by the school’s budget.48 29 IOM NUTRITIONAL GUIDELINES FOR COMPETITIVE FOODS IN SCHOOLS Congress commissioned the Institute of Medicine (IOM) to develop “the first set of recom- mended guidelines for the sale” of competitive foods, which were released in April 2007.49 The IOM concluded that “federally-reimbursable school nutrition programs should be the main source of nutrition at school, and opportunities for competitive foods should be lim- ited. However, if competitive foods are available, they should consist of nutritious fruits, vegetables, whole grains, and nonfat or low-fat milk and dairy products, consistent with the Dietary Guidelines for Americans, 2005, to help children and adolescents develop healthful eating patterns.”50 The IOM guidelines divide competitive food into 2 tiers. Tier 1 foods and beverages are recommended for all students (children and teens) during the school day or during after- school programs. Tier 2 foods, on the other hand, are only recommended for high school students after school. Tier 1 foods are fruits, vegetables, whole grains, and related combination products [com- bination products must contain a total of one or more servings as packaged of fruit, veg- etables, or whole grain products per portion] and nonfat and low-fat dairy that are limit- ed to 200 calories or less per portion as packaged and: ■ No more than 35 percent of total calories from fat ■ Less than 10 percent of total calories from saturated fats ■ Trans fat-free (less than or equal to 0.5 g per serving) ■ 35 percent or less of calories from total sugars, except for yogurt with no more than 30 g of total sugars, per 8-oz. portion as packaged ■ Sodium content of 200 mg or less per portion as packaged ■ A la carte entrée items meet fat and sugar limits as listed above and:** • Are National School Lunch Program (NSLP) menu items • Have a sodium content of 480 mg or less **200-calorie limit does not apply; items cannot exceed calorie content of comparable entrée items Examples of snacks that qualify as Tier 1 foods: apple pieces, carrot sticks, applesauce, dried fruit, whole-grain chips, nonfat and low-fat yogurt (provided they contain no more than 30 grams of total sugars per 8 oz. serving), sunflower seeds, and almonds.51 Tier 1 beverages are: ■ Water without flavoring, additives, or carbonation ■ Low-fat [i.e., one percent milk fat] and nonfat milk: • Lactose-free and soy beverages are included • Flavored milk with no more than 22 g of total sugars per 8 oz. serving ■ 100 percent fruit juice in 4 oz. portion as packaged for elementary/middle school and 8 oz. (2 portions) for high school ■ Caffeine-free, with the exception of trace amounts of naturally occurring caffeine sub- stances Tier 2 snack foods are those that do not exceed 200 calories per portion as packaged and: ■ No more than 35 percent of total calories from fat ■ Less than 10 percent of total calories from saturated fats ■ Trans fat-free (less than or equal to 0.5 g per portion) ■ 35 percent or less of calories from total sugars ■ Sodium content of 200 mg or less per portion as packaged 30 Tier 2 beverages are: ■ Nonnutritive-sweetened, non-caffeinated, non-fortified beverages with less than 5 calories per portion as packaged. Examples of snacks and beverages that qualify as Tier 2 include: baked potato chips, whole wheat pretzels, seltzer water, or caffeine free diet soda.52 The IOM recommends that schools ban sports drinks, which contain high amounts of sugar or other sweeteners, or “at the discretion of coaches, they be available to students engaged in vigorous activity lasting an hour or more.”53 THE ALLIANCE FOR A HEALTHIER GENERATION NUTRITIONAL GUIDELINES FOR BEVERAGES AND COMPETITIVE FOODS IN SCHOOLS The Alliance for a Healthier Generation is a partnership between the American Heart Association and the William J. Clinton Foundation to fight childhood obesity. The goal of the Alliance is to stop the nationwide increase in childhood obesity by 2010 and to empower kids nationwide to make healthy lifestyle choices. The Alliance will positively affect the places that can make a difference to a child’s health: homes, schools, restau- rants, doctor’s offices, and the community.54 As part of this initiative, their Healthy Schools Program is a criteria-based national recog- nition program. These criteria serve as a guide to schools that want to build healthier school environments. They are aligned with USDA guidelines and the CDC School Health Index and the Alliance will evaluate the program to inform an increased evidence base for school policy change. The criteria emphasize: ■ Foods offered as part of the National School Breakfast and Lunch Programs; ■ Food and beverages offered to children through competitive food programs in schools; ■ Quality physical and health education programs; ■ Physical activity programs; ■ After school programs that incorporate physical activity and offer children healthy snacks; and ■ Staff wellness programs In an effort to help schools improve the foods and beverages in vending machines and cafeterias, the Alliance also collaborated with leading food and beverage companies to establish beverage and competitive food guidelines. In May 2006, the American Beverage Association and representatives of the 3 largest beverage distributors, Coca-Cola, Pepsi, and Cadbury Schweppes, agreed to meet the following guidelines.55 Elementary School ■ Water ■ Up to 8 ounce servings of milk and 100 percent juice • Fat free or low fat regular and flavored milk with up to 150 calories / 8 ounces* • 100 percent juice with no added sweeteners, up to 120 calories / 8 ounces, and with at least 10 percent of the recommended daily value for 3 or more vitamins and minerals 31 Middle School ■ Water ■ Up to 10 ounce servings of milk and 100 percent juice • Fat free or low fat regular or flavored milk with up to 150 calories / 8 ounces* • 100 percent juice with no added sweeteners, up to 120 calories / 8 ounces, and with at least 10 percent of the recommended daily value for 3 or more vitamins and minerals ■ As a practical matter, if middle school and high school students have shared access to areas on a common campus or in common buildings, then the school community has the option to adopt the high school standard. High School ■ Water ■ No or low calorie beverages with up to 10 calories / 8 oz. ■ Up to 12 oz. servings of milk, 100 percent juice, and certain other drinks ▲ Fat free or low fat regular and flavored milk with up to 150 calories / 8 oz.* ▲ 100 percent juice with no added sweeteners, up to 120 calories / 8 oz., and with at least 10 percent of the recommended daily value for 3 or more vitamins and minerals ▲ Other drinks with no more than 66 calories / 8 oz. ■ At least 50 percent of non-milk beverages must be water and no or low calorie options The Guidelines apply to all beverages (outside of the formal school meal program) sold to students on school grounds during the regular and extended school day. The extended school day includes before and afterschool activities like clubs, yearbook, band, student government, drama, and childcare programs.56 The program is expected to be imple- mented in 75 percent of schools by summer 2008, with the goal of implementation in all schools by the summer of 2009.57 Compliance in state, school district, and school-specific compliance with the guidelines is on a voluntary basis. Competive Food Guidelines58 In October 2006, Campbell Soup Company, Dannon, Kraft Foods, Mars, and PepsiCo collab- orated with the Alliance for a Healthier Generation to establish nutrition guidelines for com- petitive foods sold in schools, such as snacks, side items, treats, and desserts offered for sale. The guidelines do not apply to school sponsored or school related bona fide fundraising activities that take place off of school grounds and not in transit to and from school. They also do not apply to booster sales at school related events where parents and other adults are a significant part of an audience or are selling food as boosters either during intermission or immediately before or after such events.59 The guidelines require competitive foods to meet one of the following numbered criteria: 1. Any fruit with no added sweeteners or vegetables that are non-fried. Since fresh fruits and vegetables vary in size and calories naturally, they have no calorie limit. However, calo- ries for packaged fruits and vegetables are easily ascertained according to package nutri- tion labeling. As such, calorie limits for these fruits and vegetables are specified as follows: Elementary Middle High Fresh no limit no limit no limit Packaged in own juice 150 180 200 Dried 150 180 200 2. Any reduced-fat or part-skim cheese ≤ 1.5 oz. 32 3. Any one egg with no added fat or equal amount of egg equivalent with no added fat. 4. Any other food that meets all of the following criteria: a. <35 percent of total calories from fat i. Nuts, nut butters, and seeds are exempt from above limitation and are permitted. b. <10 percent of calories from saturated fat -OR- <1g saturated fat c. 0 g trans fat d. <35 percent sugar by weight e. <230 mg sodium i. Lowfat and fat free dairy products can have <480mg sodium ii. Vegetables with sauce, and soups can have <480mg sodium if they contain one or more of the following: >2g fiber; or >5g protein; or >10 percent DV of Vitamin A, C, E, folate, calcium, magnesium, potassium, or iron; or > 1/2 serving (1/4 cup) of fruit or vegetables. iii. Soups described in Addendum 2 are exempt and are permitted until August 31, 2008. f. If products are dairy, they must be non-fat or low fat dairy. g. Meet 1 of the following calorie requirements: i. <100 calories ii. Vegetables with sauce and soups meeting 3.e above can have 150 calories if they contain 2 or more of the following: >2g fiber; or >5g protein; or >10 percent DV of Vitamin A, C, E, folate, calcium, magnesium, potassium, or iron; or > 1 /2 serving (1/4 cup) of fruit or vegetables. iii. Other foods can have calorie limits per below if they contain one or more of the following: >2g fiber; or >5g protein; or >10 percent DV of Vitamin A, C, E, folate, calcium, magnesium, potassium, or iron; or > 1/2 serving (1/4 cup) of fruit or vegetables: ■ <150 calories for elementary schools ■ <180 calories for middle school ■ <200 calories for high school. Addendum 1 - Total and Saturated Fats Products with < 7 percent of calories from saturated fat will be allowed to have <40 per- cent of calories from total fat until August 31, 2008. By this date, products with <7 per- cent of calories from saturated fat must provide <35 percent of calories from total fat.60 Addendum 2 - Sodium A variety of commercially available soup products available in bulk through food service channels to schools can meet all the requirements specified in the Guidelines except for an upper limit of 480 mg for sodium. In recognition of this market availability, soups that meet the sodium requirement specified in this Addendum will be considered to meet the Guidelines until August 31, 2008. This transition period will provide manufacturers time for product reformulation, as well as the ability to meet manufacturing and food service distribution requirements. For individual serving packages, these nutritional guidelines are defined for a whole pack- age as labeled on the package’s nutrition facts panel. In the event that the food is bought in bulk but served individually, such as on an à la carte line, then the criteria apply to the serving size actually offered to students. 33 HEALTH AND NUTRITION EDUCATION IN SCHOOLS Healthy People 2010 states that health education should include information about the consequences of unhealthy diets and inadequate physical activity. Health education seeks to teach students about maintaining good health, including the proper nutrition and the value of physical activity, which are key to controlling obesity. CDC notes that health education can effectively promote students’ health- related knowledge, attitudes, and behaviors.61 These education programs are intended to help stu- dents set a foundation for maintaining good nutritional habits and a physically active lifestyle. ■ Only 2 states -- Colorado and Oklahoma -- do not require schools to provide health education. BMI and Obesity-Related Health Screening Initiatives in Schools A number of states have undertaken initiatives to screen BMI or other obesity-related meas- ures in schools. The results overall are intended to help the states identify schools, school districts, and student populations that may need interventions to help reduce the rates of overweight children and youth. ■ Twelve states -- Arkansas, California, Delaware, Florida, Illinois, Kansas, Maine, Missouri, New York, Pennsylvania, Tennessee, and West Virginia -- have passed legis- lation enabling schools to test students’ BMI levels as either part of health examina- tions or physical education activities. In addition, Iowa requires the measurement, reporting and tracking of height and weight under an elementary school pilot program; Louisiana requires the assessment of changes in the weight status of students participating in a three-year nutrition and physical activity pilot program; Massachusetts mandates the annu- al measurement of each student’s weight and height; and South Carolina requires fitness reports of students to be sent home to parents in the 5th and 8th grades and in high school. In addition, in 2003, California and Illinois enacted legislation requiring risk analysis and non- invasive screening of students for diabetes. In 2005, California also enacted a ballot initiative that encourages additional diabetes awareness and prevention efforts. Two other states, Pennsylvania and Texas, considered legislation to screen students for their potential at risk sta- tus for type 2 diabetes, but the initiatives were not enacted. ■ Two states have enacted legislation requiring screening students for risk of type 2 diabetes -- California and Illinois. 34 CDC’S SCHOOL HEALTH PROGRAM GRANTS ■ Only 23 states received funds to support CDC’s school health program that encourages behaviors to help reduce students’ risk of obesity in 2006, including Arkansas, California, Colorado, Florida, Hawaii, Indiana, Kansas, Kentucky, Maine, Massachusetts, Michigan, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Washington, West Virginia, Wisconsin. The average grant award was $416,000. CDC’s Division of Adolescent and School Health (DASH) awarded cooperative agreement grants to 23 states to improve school health programs and policies designed to help young people avoid behaviors that increase risk for obesity and chronic disease. Each state department of education is the lead agency for these grants and works in partner- ship with the state department of health to strengthen school-based policies and programs that address obesity and chronic disease. The DASH grants support: ■ The planning and coordination of school-based programs that address all aspects of health in a school, including physical education and other physical activities, nutritional services, health education, school employee wellness, counseling, psychological, and social services, health services, family and community involvement, and healthy school environment; ■ The implementation of the school health guidelines that address physical activity and healthy eating; ■ Statewide assessments of critical health behaviors that contribute to obesity and over- weight in youth; ■ Local level assessment of school health programs; ■ The building of effective partnerships among state-level government and non-governmental agencies in support of school health programs and policies; and ■ The establishment of a state technical assistance and resource plan for school districts and schools. C. COMMUNITY-FOCUSED OBESITY LEGISLATION AND FEDERAL GRANTS TO STATES TFAH has also examined a number of state grants from CDC for obesity-related programs. obesity-related policies and actions that are Additional detail about the snack tax and obe- aimed at the general population. These sity liability laws is available in the Supplement include tax policies, litigation restrictions, and to F as in Fat on TFAH’s Web site. SNACK TAXES One way many states have tried to impact the obesity epidemic is by taxing junk foods in an attempt to reduce people’s consumption of these products. The National Governors Association’s Center for Best Practices and the World Health Organization (WHO) have noted that taxes on junk foods are possible tools governments can use to influence consumer choices.62,63 Seventeen states and D.C. currently have laws that tax foods of low nutritional value:64 Arkansas, California, D.C., Illinois, Indiana, Kentucky, Maine, Minnesota, Missouri, New Jersey, New York, North Dakota, Rhode Island, Tennessee, Texas, Virginia, Washington, and West Virginia. These taxes are very controversial. Proponents of the taxes argue that a tax on junk food could be used to fund a healthy eating and nutritional information campaign.65 Opponents argue that junk food taxes are regressive and unlikely to encourage people to substitute healthier foods for junk food.66 Some public health officials view the positive impact on taxing tobacco products in reducing smoking as a model for taxing snack foods and sodas to promote healthier behavior. 35 LEGISLATION FOR LIMITING OBESITY LIABILITY Many states have responded to the obesity epidemic by passing laws that prevent individuals from suing restaurants, manufacturers, and marketers for contributing to unhealthy weight and related health problems. These laws that limit liability are fairly controversial, and have been prompted by fears of obesity lawsuits similar to tobacco lawsuits. However, they are one of the most visible sets of obesity-related policies to emerge in recent years. Twenty-four states have passed obesity liability laws: Arizona, Colorado, Florida, Georgia, Idaho, Illinois, Indiana, Louisiana, Kansas, Kentucky, Maine, Michigan, Missouri, New Hampshire, North Dakota, Ohio, Oregon, South Dakota, Texas, Tennessee, Utah, Washington, Wisconsin and Wyoming. Proponents of these bills argue that the central issue is “common sense and personal responsibility.”67 Passage of the bill indicates a level of support for the view that obesity is an individual health issue. Supporters also endorse a statement from the White House that “food manufacturers and sellers should not be held liable for injury because of a person’s con- sumption of legal, unadulterated food and a person’s weight gain or obesity.”68 Opponents of limited liability laws support the position that “it’s impossible for consumers to exercise personal responsibility when businesses are concealing important information about their products,” such as the number of calories in restaurant food or lack of consistency in food labeling.69 CDC GRANTS FOR STATE-BASED NUTRITION AND PHYSICAL ACTIVITY PROGRAMS ■ Only 28 states receive funds from the CDC for state-based nutrition and physical activity programs aimed at reducing the rates of obesity and other chronic diseases. CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) awarded cooperative agree- ment grants to 28 states to help improve their efforts to prevent obesity and other chronic diseases. Basic implementation grants help support states to: ■ Conduct and evaluate nutrition and physical activity interventions; ■ Train health care providers and public health professionals; ■ Provide grants to communities for local obesity prevention initiatives; ■ Make environmental changes to encourage access to healthful foods and places to be active; and ■ Strengthen obesity prevention programs in community setting such as preschools, childcare centers, work sites, and health care settings. Seven states received basic implementation grants in 2006, with an average award of $1,022,114: Colorado, Massachusetts, New York, North Carolina, Oregon, Pennsylvania, and Washington. Capacity building grants help states to: ■ Hire staff with expertise in public health nutrition and physical activity; ■ Build broad-based coalitions; ■ Develop state nutrition and physical activity plans; ■ Identify community resources and gaps; ■ Implement small scale interventions; and ■ Work to raise public awareness of systemic changes needed to help state residents achieve and maintain a healthy weight. Twenty-one states received “capacity building” grants in 2006, with an average award of $420,186: Arizona, Arkansas, Florida, Georgia, Illinois, Iowa, Kentucky, Maine, Maryland, Michigan, Missouri, Montana, New Mexico, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Vermont, West Virginia, and Wisconsin. 36 D. EXAMPLES OF STATE OBESITY MEDICAID HEALTH CARE BENEFITS This section examines examples of how improve preventive care and treatment. It some state Medicaid programs are offering also reviews state policies for reimbursing obesity-related benefits, particularly to obesity surgery and obesity drugs. EXAMPLES OF STATE MEDICAID AND STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP) EFFORTS WEST VIRGINIA At more than $2.1 billion, West Virginia’s Medicaid and SCHIP program is the largest item in the state budget. It is estimated that the state spent nearly $140 million on “medical and pharmacy costs related to obesity” in 2002 alone.70 Given the high budgetary strain of obesity on the state, West Virginia is implementing initiatives within its Medicaid program to encourage enrollees to adopt healthier lifestyles. ■ West Virginia is offering enrollees an optional, extended benefits package in an effort to promote healthier living among the state’s Medicaid population.71 The extended benefits package includes coverage for nutrition education, diabetes care, and cardiac rehabilita- tion.72 In addition, it gives enrollees the opportunity to earn credits toward health services in a Healthy Rewards Account.73 ■ In January 2007, West Virginia began offering obese Medicaid recipients enrolled in UniCare, the largest provider of Medicaid in the state, 16 weeks of free Weight Watchers courses.74 If the Weight Watchers program proves successful in West Virginia, Wellpoint Inc., the parent company of UniCare, may look into expanding the program to the following 14 states where the company also provides healthcare coverage: California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, and Wisconsin.75 West Virginia’s extended benefits program requires individuals to sign a “personal responsibility” member agreement. “Individuals who do not meet their responsibilities” are moved out of the program, whether or not they still have obesity-related health problems.76 Some public health experts question the effectiveness of removing people who do not meet specific program requirements but are at risk for a range of obesity-related health conditions. TENNESSEE TennCare, Tennessee’s Medicaid agency, also has begun covering $120 for 12 weeks of Weight Watchers meetings for each Medicaid enrollee who wants to participate in the program. To remain enrolled in the program, participants must pay a $1 co-pay at each meeting, attend 10 of the 12 weekly meetings, and achieve their targeted weight loss for the 12 week period.77 In 2006, TennCare completed a pilot run of the program, which included 1,400 Medicaid benefi- ciaries who lost a combined total of more than 8,000 pounds over a six month period.78 COLORADO AND IOWA In 2005, 2 pieces of legislation were enacted to combat obesity among state Medicaid populations. ■ Colorado passed a law calling for the development and implementation of an obesity treat- ment pilot program for obese Medicaid enrollees. In order to be eligible for the program, patients must have a BMI equal to or greater than 30 and an obesity-related disease, such as diabetes, hypertension, and coronary heart disease. The program is designed to treat a recipient through the use of behavioral modification, self-management training, and medica- tion when medication is medically necessary.79 ■ In Iowa, legislation requires “the state’s Medicaid program to develop a strategy for provid- ing dietary counseling to child and adult Medicaid enrollees by July 1, 2006.”80 37 NEBRASKA’S HEALTH CHECK PROGRAM Nebraska’s program, known as HEALTH CHECK, is available to all Medicaid-eligible individuals age 20 and younger and covers: ■ Nutrition Counseling: Eligible children and adolescents can receive short term one-on-one nutri- tional counseling sessions. Under HEALTH CHECK rules, “nutritional problems or conditions that are considered appropriate for nutritional counseling” include obesity and “excessive weight gain.”81 ■ Weight Management Clinics: Weight management services are only covered “when the child is documented to be clinically overweight.” The program must include: (1) a moderate calorie diet well balanced in macronutrients; (2) an exercise program; (3) family involvement; (4) behavior modification; and (5) a developmentally-appropriate approach for the child’s age group.82 ARIZONA’S CHILDHOOD OBESITY PREVENTION PROGRAM The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid system, has begun implementing its Childhood Obesity Prevention Program. The program includes 4 tiers of education and intervention for nutrition/healthy eating, physical activity, behavior management and support for children who are, or are at risk of, becoming overweight and their families.83 ■ TIER 1: focuses on obesity prevention. Risk factors (e.g., family history, birth weight, socioe- conomic factors, etc.) for obesity are assessed for each patient (3 to 20 years old) and BMI is calculated. The primary care physician is advised to focus on educating both the parent and child about “healthy family eating patterns” and limiting t.v./video to 2 hours per day. The physician is also advised to promote “family physical activity.”84 ■ TIER 2: If tier 1 prevention techniques have failed, the primary care physician is advised to con- tinue to educate the family and child about healthy eating and physical activity habits. The guide- lines advise the primary care physician to recommend medical nutritionist/dietician consultation and motivational/behavioral therapy consultation. Two visits per year to a dietician for medical nutrition therapy and 2 visits per year for motivational/behavioral therapy are covered.85 ■ TIER 3: If tier 2 recommendations have failed and there are health complications (e.g., elevated blood pressure), the primary care physician is advised to recommend family exercise physiologist consultation. In addition, the primary care physician is advised to increase family nutritionist/dieti- cian consultations and family motivational behavioral therapy consultations. Finally, the primary care physician is advised to conduct an indepth medical assessment, including lab work up, of the child.86 ■ TIER 4: If tier 3 recommendations have failed and a “willingness to change/desire to change” has been identified within the patient, the guidelines recommend that the patient enroll in a Center of Excellence for Obesity Management program. Both parent and child must agree to participate in and complete the program. The program must have a family approach and incorporate an individualized curriculum. If depression is identified within the patient at tiers 2, 3, or 4, depression management services are covered.87 1. More Than 40 States Offer Medicaid Reimbursement for Weight-Loss Surgeries As of 2004, 42 state Medicaid programs Oklahoma, Oregon, Pennsylvania, Rhode offered coverage for gastric bypass surgery: Island, South Carolina, Utah, Virginia, Alabama, Alaska, Arkansas, California, Washington, West Virginia, Wisconsin, and Colorado, Connecticut, Florida, Georgia, Wyoming.88 Hawaii, Idaho, Illinois, Indiana, Iowa, Note: The Medicaid programs in Arizona and Kansas, Kentucky, Louisiana, Maine, Mary- Tennessee are managed care. Therefore, obe- land, Massachusetts, Michigan, Minnesota, sity-related coverage decisions are made by Mississippi, Missouri, Nebraska, Nevada, the individual managed care organizations New Hampshire, New Jersey, New Mexico, and not the state.89 New York, North Carolina, North Dakota, 38 PRIVATE COVERAGE OF WEIGHT-LOSS SURGERIES Many within the health care sector believed that after Medicare began covering a range of weight-loss surgeries, private insurers and employers would do the same. However, that has not necessarily been the case due to insurers’ and employers’ concerns over the cost of the procedures and the risk of health complications and death associated with the surgeries. Each operation costs between $15,000 and $20,000 (and when the cost of evaluations, follow-up care and counseling are added in, the process can run from $35,000 and $50,000).90, 91 In fact, some private insurers are scaling back their coverage of bariatric surgeries due to cost concerns. In 2005, Blue Cross and Blue Shield of Florida (BCBSFL) announced that it would no longer pay for weight-loss surgeries. Barry Schwartz, vice president of care and network management for BCBSFL said this was largely because of the procedure’s more than 20 per- cent complication rate. In addition, BCBSFL has spent nearly $200 million on weight-loss sur- geries over the past 3 years. “People need to know what a proper diet is and have good access to a doctor who will work with them and monitor them,” said Dr. Schwartz. “Beyond that, there is really remarkably little that has proven to be effective.”92 Some private insurers do cover weight-loss surgeries, but with caveats. ■ Humana of Texas and Blue Cross and Blue Shield of Texas are excluding coverage of weight-loss surgeries for their members but will coordinate coverage “for large employers that choose to add coverage under a rider to their benefit policies.”93 However, due to concerns over complications and risks associated with the surgeries, the insurers will only grant coverage to these large employers if the weight-loss surgeries are performed in Centers of Excellence, similar to the requirements of Medicare.94 ■ Blue Cross and Blue Shield of Massachusetts (BCBSMA) will only reimburse hospitals for weight-loss surgeries if the hospitals have been “certified as outstanding providers of weight-loss surgery” by the American College of Surgeons (ACS) or the Surgical Review Corp (SRC), “a nonprofit set up by groups and organizations interested in improving bariatric surgery outcomes.”95 BCBSMA implemented the requirement in hopes that it will “improve outcomes for patients undergoing” weight-loss surgeries. BCBSMA was “the first BCBS insurer in the country to require hospital certification for weight-loss” surgeries. The Blue Cross and Blue Shield Association and Blue Cross and Blue Shield of North Carolina (BCBSNC) have since established similar standards.96 ■ Tufts Health Plan will only cover weight-loss surgeries performed by “center of excellence” providers.97 However, in March 2007, Tufts made its requirements for coverage more strin- gent by “requiring obese patients to participate in a yearlong lifestyle modification program before being eligible for” weight-loss surgeries.98 2. States Medicaid Reimbursements for Major Weight-Loss Drugs According to a review of state Medicaid pro- morbid obesity. These states include: grams that offer coverage of weight-loss Alabama, Arizona, Colorado, Georgia (only drugs, based on the State Pharmacy lists as for Fee For Service plans), Hawaii, Iowa, of 2006-07, 17 states offer coverage of Idaho, Kansas, Louisiana, Montana, weight-loss drugs if a patient meets criteria Nebraska, New Hampshire, Rhode Island, for being diagnosed with a health condition Texas, Vermont, Virginia, and Wisconsin.99 such as type 2 diabetes, hperlipidemia, or 39 Federal Responsibilities and Policies 3 SECTION T he federal government has developed a variety of initiatives to combat obesity and related health concerns. In the 2004 and 2005 editions of the F as in ■ Difficulties in balancing the competing Fat report, TFAH outlined obesity responsi- interests and priorities of industry and bilities and policies at a range of federal the public health community; and agencies. TFAH found that these efforts ■ An emphasis on the traditional develop- largely fall into 3 categories: ment of construction rather than build- ■ Public education campaigns targeted at ing public transportation or the develop- individual behaviors; ment of community spaces that encour- age people to be active. ■ Treatment of obesity-related diseases; and While many departments and agencies work on ■ Initial steps toward developing community obesity-related issues, there is no federal gov- active living incentives. ernment wide approach or coordination of Obstacles TFAH found that hinder a more these efforts. While obesity is primarily a health strategic, coordinated obesity policy include: issue, almost every other aspect of government has programs and policies that impact nutrition ■ Lack of designated leadership and a and activity, ranging from community and high- frequent silo approach that result in a way development to agriculture policy to busi- lack of coordinated effort among relat- ness incentives for locating supermarkets in ed agencies; low-income neighborhoods. EXAMPLE OF GOVERNMENT-WIDE APPROACH TO A PUBLIC HEALTH PROBLEM In 2005, the Administration released a national strategy and a federal government wide plan with detailed steps and benchmarks for each agency for pandemic flu preparedness. That comprehensive approach to dealing with a wide reaching public health problem serves as an example for policymakers focused on obesity. 41 OVERVIEW OF SOME KEY FEDERAL AGENCIES’ INVOLVEMENT IN OBESITY POLICY More details on these programs are available in the 2004 and 2005 editions of F as in Fat. Dietary Guidelines for Americans -- A Joint U.S. Department of Health and Human Services (HHS) and USDA Initiative -- released in 2005 and aimed at providing people with advice about good dietary habits. HHS is involved in more than 300 obesity-related programs nationwide. Most of the agen- cies within HHS are involved in obesity-related programs, including: CDC which oversees the National Center for Chronic Disease Prevention and Health Promotion, including grant programs for states such as the Division of Adolescent and School Health (DASH), Division of Nutrition, Physical Activity, and Obesity (DNPAO), and the Steps to a HealthierUS pro- gram. The National Center for Environmental Studies also studies the relationship between the built environment (land use, urban planning, and transportation) and health issues including obesity. The DNPAO is nearing completion of a strategic planning and reorganization progress which aims to: ■ Enhance CDC’s capacity to lead public health efforts related to nutrition, physical activity, and obesity prevention and control; ■ Strengthen the link between scientific research and program activities; ■ Highlight and expand relationships with states, communities, and other partners in pro- moting nutrition, physical activity, and obesity prevention and control; and ■ Increase translation and dissemination activites in support of programs. Centers for Medicare and Medicaid Services (CMS) where Medicare and Medicaid are estimated to pay over half of the nation’s obesity-related health care costs. Food and Drug Administration (FDA) which oversees food labeling requirements and a “Calories Count” initiative. FDA also “encourages” restaurants to make nutritional informa- tion available to consumers. FDA also oversees the approvals of weight-loss drugs. National Institutes of Health (NIH) conducts research and education programs. In 2003, NIH created a Strategic Plan for NIH Obesity Research focusing on research into lifestyle modi- fications, medical approaches, linkages between obesity and health, and studying health dis- parities related to obesity. A number of Institutes at NIH also manage obesity and obesity- related disease management public education campaigns. The National Institute of Environmental Health Sciences is also examining how the built environment impacts obesity. Health Resources and Services Administration (HRSA) which aims to expand health care coverage for all Americans manages a range of programs such as the Maternal and Child Health Bureau and the Bright Futures Initiative that focus on promoting healthy behaviors. Other HHS offices, including the Surgeon General’s Office, the Office of Women’s Health, the Indian Health Service, and the Administration on Aging manage obesity- related public education campaigns. President’s Council on Physical Fitness and Sports encourages Americans to be more active and manages the President’s Challenge awards program through schools. USDA is responsible for a range of food and nutrition programs that impact obesity, including nutritional advice and guidance; food and obesity education campaigns; distribution of food products to schools; oversight and protection of the nation’s agricultural and dairy markets. USDA’s Food and Nutrition Service (FNS) oversees the Food Stamp Program; the Women, Infants, and Children Program (WIC); the National School Lunch Program; and the Child and Adult Care Food Program. 42 Federal Trade Commission (FTC) regulates advertising of food and diets. It has focused on attempts to limit marketing “junk food” to children. FTC also monitors possible false adver- tising about diets products and healthiness of foods. A number of companies have undertaken self-regulation efforts over the past year, including Kraft Co., Kellogg Co., and Walt Disney Co. In addition a number of companies announced new self-restriction policies for marketing to children under age 12 in July 2007, including Coca-Cola Co., McDonalds Corp., PepsiCo, General Mills Inc., Campbell Soup Co., Hershey Co., Unilever, Masterfoods USA, Kraft Foods Inc., and Cadbury Adams.100 Decisions about voluntary restrictions vary on a company by company basis. For example, General Mills announced it will limit advertising of Trix cereal to children under age 12, but will not limit marketing of Cocoa Puffs, which has less than one gram of sugar per serving. As another example, PepsiCo, which owns Frito-Lay, Quaker Foods, Pepsi and Gatorade, will only advertise 2 of its products to children under 12, Baked Cheetos Cheese Flavored Snacks and Gatorade drinks.101 Department of Defense (DOD) oversees the health of the military. DOD has developed a number of programs to combat obesity in the armed services. An estimated 16 percent of active duty military are currently obese and 18.9 percent of active duty soldiers under the age of 21 are obese.102 Almost one-third of 18 year olds who applied for service in all branches of the military in 2005 were overweight, according to a recent report by the Army.103 DOD also partners with the FNS on the DOD Fresh Fruit and Vegetable Program to supply fresh fruit and vegetables to schools. Department of Veterans Affairs (VA) serves over 6 million veterans. Nearly 70 percent of these veterans are overweight and approximately 30 percent are obese.104 Office of Personnel Management (OPM), in an effort to reduce the demands on the health care system and associated costs for federal employees, has launched initiatives to edu- cate the federal civilian workforce and retirees about healthy living and best health care strategies. HHS, USDA, DOD, and the Department of the Interior (DOI) created a Memorandum of Understanding to Promote Public Health and Recreation to support the use of public lands and water resources for physical activity and recreation. The memorandum particularly cites outdoor recreation as integral to a healthy and physically active lifestyle.105 The DOI’s National Park Service provides funding for the Land and Water Conservation Fund, a match- ing federal grant program that assists states and localities in acquiring and developing public outdoor recreation areas and facilities. The Federal Highway Administration and Environmental Protection Agency (EPA) have undertaken some efforts to work with states to redesign large highway and roadway projects.106 EPA has a brownfields initiative devoted to clean up assistance and redevelopment of former commercial and industrial sites which are abandoned or contaminated with hazardous sub- stances or pollutants. Many of these brownfields are redeveloped into public space which can provide increased venues for recreation. Department of Education administers the Carol M. White Physical Education Program, which offers competitive grants for the initiation, expansion, and improvement of physical education programs for K-12 students. Department of Transportation (DOT) offers grants through the Federal Safe Routes to School Program. The grants provide funding for infrastructure improvements and educational programs, such as building safe street crossings and establishing programs to encourage children to walk and bike to school. 43 MEDICARE REIMBURSEMENT OF OBESITY TREATMENTS In July 2004, HHS “eliminated the long-held Medicare policy statement that obesity was not a disease” from the Medicare Coverage Issues Manual.107,108 Some experts believe this may lead to increased federal health insurance coverage of obesity treatments.109 Up until February 2006, gastric bypass surgery (known as Roux-en-Y bypass) was the only weight-loss surgery covered by Medicare.110 The federal agency now also covers laparoscopic adjustable gastric banding (involves using a band to “pinch off a small portion of the stomach”) and open and laparoscopic biliopancreatic divisions (involves “surgically bypassing most of the small intestine and pancreas”).111, 112, 113 To qualify for weight-loss surgery under the new policy, Medicare recipients “must have unsuccessfully tried other treatments, have a BMI of more than 35 and also suffer from weight-related problems, such as diabetes, heart disease or sleep apnea,” and the surgery must be performed at a certified facility.114 See below for more discussion of covering childhood obesity and the State Children’s Health Insurance Program Reauthorization Act of 2007. Below are 5 major federal obesity-related C. Reauthorization of the State Children’s issues that have been under consideration Health Insurance Program (SCHIP) Act; this past year: D. Funding for CDC Obesity Grants; and A. Reauthorization of the Farm Bill; E. Acceleration of the Obesity Prevention B. Reauthorization of No Child Left Behind; Research Agenda. A. REAUTHORIZATION OF THE FARM BILL The Farm Bill will be reauthorized in 2007. Consumer and industry economics also con- The legislation can be an important vehicle tribute to the country’s obesity problem. to improve federal nutrition programs and ■ Low-income families consume fewer help combat the obesity epidemic. fruits and vegetables than higher-income A number of dietary factors are contribut- families.117 ing to increased levels of obesity in America, ■ People in low-income areas often pay ranging from higher caloric density of foods more for nutritious foods such as fresh to limited access to nutritious fresh foods in fruits and vegetables.118 many areas to outdated nutrition standards for foods sold in schools. Currently, the typ- ■ The costs of fruits and vegetables have ical American diet does not include enough increased 40 percent since 1985, while the fruits and vegetables. costs of fats and sugars have declined.119 ■ Only one in 5 Americans consumes the The Administration’s Farm Bill proposal recommended amount of fruit each day.115 would increase mandatory funding for the purchase of fruits and vegetables for nutri- ■ Children under the age of 18 generally tion programs, make some reforms to the consume 50 percent or less of the recom- Food Stamp Program, support school mended levels of fruits and vegetables.116 efforts to provide meals based on the Dietary Guidelines for Americans, 2005, and launch a USDA Initiative to Address Obesity Among Low-Income Americans. 44 FRUIT AND VEGETABLES: PRODUCTION IMPACTS CONSUMPTION ■ To meet the 2005 Dietary Guidelines for Americans for fruit, Americans on a 2,000 calorie per day diet would need to increase fruit consumption by 132 percent. In order for this increase to occur, U.S. production of fruit would need to increase 117 percent and U.S. agriculture would need to harvest 4.1 million more acres of fruit over 1999-2003 production levels.120 ■ To meet the guidelines for vegetables, Americans on a 2,000 calorie per day diet would need to increase daily consumption of vegetables by 31 percent. However, when you take into account the five vegetable subgroups in the Guidelines, Americans would have to increase their consumption of legumes, orange vegetables, and dark-green vegetables by 431 percent, 183 percent, and 175 percent respectively. Overall, U.S. farmers would “need to harvest 15.3 million acres of vegetables per year for Americans to meet” the Guidelines vegetable recommendations, “an increase of 137 percent (8.9 million harvested acres) over 1999-2003 levels.”121 While the Dietary Guidelines for Americans were updated in 2005, the National School Lunch Program (NSLP) and the Food Stamp Program have yet to be updated to meet the recom- mended nutrition standards. In FY 2005, an average of 29.6 million children participated in NSLP each school day, representing around 60 percent of all children attending a school or institution participating in NSLP That same fiscal year, an average of 25.7 million individuals . per month participated in the Food Stamp Program, an 8 percent increase over FY 2004.122 According to USDA’s FY 2007 Farm Bill proposal, the agency “is in the process of developing a proposed regulation to better align school meal requirements with the 2005 Dietary Guidelines for Americans.”123 The Administration proposal also contains USDA plans to increase funding for fresh fruits and vegetables to help schools meet the 2005 guidelines. The Farm Bill could impact a wide range of Stamp Program, farmers’ markets, and farm other policies related to schools, the Food subsidies for fruits and vegetables, including: For Schools ■ Expanding USDA’s Fresh Fruit and ■ Increasing funding for the Department of Vegetable Snack Program to every state, Defense Fresh Program, which offers and increase funding for the program. In schools a wider variety of fresh produce FY 2006, only approximately 400 schools than would normally be available in the in 14 states and 3 Indian reservations School Lunch Program through USDA received support for this program. purchases. ■ Restricting the sale of foods of poor nutri- tional value in schools. For the Food Stamp Program ■ Updating the Food Stamp Program to meet ■ Authorizing a pilot program to provide a the Dietary Guidelines for Americans, 2005. monetary incentive on the program’s Electronic Benefits Transfer card for purchas- ■ Increasing the minimum food stamp ing fruits, vegetables, and whole grain foods. benefit so recipients can more easily afford fruits and vegetables and purchase ■ Strengthening the Food Stamp Nutrition Edu- foods that meet the Dietary Guidelines for cation Program to include more comprehen- Americans, 2005. sive public health approaches and include a broader definition of nutrition education. 45 For Farmers’ Markets ■ Providing subsidies to farmers’ markets to ■ Increasing research in ways to increase accept Electronic Benefits Transfer cards access to fresh fruits and vegetables in from the Food Stamp Program. low-income communities including trans- portation options to make it easier for ■ Providing grants as incentives for creating people to get to farmers’ markets. more farmers’ markets, especially in underserved communities. ■ Expanding the Seniors Farmers’ Market Nutrition Program. For Farm Fruit and Vegetable Subsidies ■ Examining subsidies for growing fruits corn.124 Corn, wheat, soybeans, rice, and and vegetables. Currently, federal farm cotton are “program crops” that receive programs that provide income to support government subsidies ranging from $10 field crop producers do not apply to the billion to $25 billion a year.125, 126 fruit and vegetable industries other than CROP SUBSIDIES AND EATING HABITS Americans’ dietary habits are likely influenced by which crops are subsidized. Currently corn, wheat, soybeans, rice, and cotton are the crops that are most heavily subsidized by the government. ■ One analysis of eating patterns in 2002 found that Americans consume an average of 300 more calories a day than in 1985. Of this 300 calorie increase, 46 percent are grains (primarily less healthy refined grains); 24 percent are added fats; 23 percent are added sugars and sweeteners; 8 percent are fruits and vegetables; and meat and dairy declined by one percent.127 Source: Economic Research Service, USDA, 2002 ■ Wheat constitutes 71 percent of U.S. grain consumption.128 On average, Americans eat 10 servings of grains a day, 9 of which are refined grains with limited fiber content, and only one serving is a whole grain food. The 2005 Dietary Guidelines for Americans recommend at least a 3 ounce servings of whole grain foods per day.129 ■ Soybean oil “accounts for 75 percent of the fat in processed foods and is commonly hydro- genated to create trans fats.”130 Soybean oil also accounts for approximately “two-thirds of all the vegetable oils and animal fats consumed in the United States.”131 ■ High-fructose corn syrup, which is processed from corn, “is the most widely used caloric sweetener in the United States.”132 Average per capita annual consumption of high fructose corn syrup grew by 129 percent between 1980-84 and 2000.133 46 B. REAUTHORIZATION OF NO CHILD LEFT BEHIND The Elementary and Secondary Education on students’ academic achievement, includ- Act, often called the No Child Left Behind ing increased concentration, improved math- Act, is up for reauthorization in 2007. Parts ematics, reading, and writing test scores, and of the legislation could influence how phys- also reduced disruptive behavior.134, 135 ical education and physical activity are A list of recommendations from the NCPPA included within school. for ways to increase physical education and According to the National Coalition for activity in school and around schools is Promoting Physical Activity (NCPPA), studies included in the Section 4: Promoting demonstrate that physical education and Physical Activity as a Strategy to Improve physical activity programs have positive effects Health of this report. C. REAUTHORIZATION OF THE STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP) ACT The State Children’s Health Insurance Beneficiaries found to be overweight or obese Program (SCHIP) is designed to help states are eligible for additional benefits including: insure more children. The program is up ■ Up to 6 visits to licensed and credentialed for reauthorization in 2007 and could take nutritionists for nutrition counseling. steps to further address the childhood obe- sity crisis by including a health insurance ■ Access by phone to a nurse health coach. style benefit for obesity-related services to ■ Up to 4 physicians visits a year for the eval- children enrolled in the program. uation and treatment of obesity. Most private insurance plans do not provide ■ No cost sharing shall be expected of the coverage for obesity-related services, thus beneficiary for these benefits. these benefits may not be part of the “benchmark” plans from which SCHIP cov- Nutrition counseling is defined based on a erage is developed. In order to more effec- 1997 recommendation from a committee at tively address rising childhood obesity rates, the HRSA Maternal and Child Health Bureau: basic anti-obesity benefits could be covered ■ The Committee suggests that a clinical to SCHIP beneficiaries. There is precedent dietician or nutritionist can work with the for this sort of coverage as Medicare covers child and his family members to achieve a medical nutrition therapy for beneficiaries health approach to eating. The with diabetes or renal disease. But the Committee believes that “changes in diet Medicare benefit, which is aimed at adults are more likely to be achieved if the clini- used to dealing with medical advice, coun- cian involves the entire family; recom- seling, and treatment, may not be adequate mends one or 2 small changes at a time for children covered by SCHIP. (e.g. the elimination of one or 2 high The childhood obesity-related benefits Blue calorie foods from the family’s diet); Cross Blue Shield of North Carolina (BCB- teaches problem-solving, especially how SNC) offers can serve as a model for what to handle eating outside the home and could be included in such a benefit. saboteurs (i.e. people who interfere with the family’s changes in eating habits or In the BCBSNC model, all beneficiaries are physical activity level); and follows the screened for obesity and overweight as part family closely.”136 of routine visits to physicians. This screening is covered by BCBSNC and beneficiaries are not expected to pay any further cost sharing. 47 D. FUNDING FOR CDC OBESITY GRANTS The proposed budget from the across the country to show how local initia- Administration for FY 2008 calls for cuts tives can reduce the burden of chronic dis- to a number of cooperative agreement eases such as obesity, diabetes, and asthma grant programs that focus on obesity pre- by encouraging people to be more physical- vention and health promotion at CDC, ly active, eat a healthy diet, and not use including the Division of Nutrition, tobacco.141 Through a 5-year cooperative Physical Activity, and Obesity; Division of agreement, Steps has provided grants to 25 Adolescent School Health; and Steps to a small cities/rural communities, 12 large Healthier U.S. grant programs.137 cities/urban communities, and 3 tribal enti- ties. In all, Steps is active in 17 states in some ■ Division of Nutrition, Physical Activity, capacity. Steps programs have demonstrat- and Obesity (DNPAO): Through its ed progress in reducing obesity in commu- Nutrition and Physical Activity Program nity-based interventions; reducing chronic to Prevent Obesity and Other Chronic disease risk factors and health care costs in Diseases (NPAO), DNPAO funds pro- workplaces; creating healthier school envi- grams that use various nutrition and phys- ronments including provision of nutritious ical activity intervention strategies to foods and physical activity enhancements; address obesity and other chronic dis- and reducing A1c levels among diabetes eases.138 The program is currently avail- patients. The Administration has proposed able to only 28 states due to limited funds. cutting the Steps program by nearly 40 per- ■ Division of Adolescent School Health cent ($17.3 million). (DASH): As part of its mission to prevent The budget is calling for a new Adolescent the most serious health risk behaviors Health Promotion Initiative as the Steps to a among children, adolescents and young Healthier U.S. is being eliminated and past adults, DASH currently provides funds to programs like VERB have been discontinued. establish and run a statewide coordinated school health program.139 School health ■ Adolescent Health Promotion Initiative: programs encompass health and physical The Administration has proposed new education, school meals, health services, funding - - $17.3 million - - to establish a and healthy school environments. These program that aims to help schools school programs tackle a range of health encourage regular physical activity, issues, including “reducing chronic dis- healthy eating, and injury prevention. ease risk factors including tobacco use, Under the program, schools would have poor nutrition, and physical activity.”140 access to the HHS School Health Index to The program is currently available to only make self-assessments, develop action 23 states due to limited funds. plans, and apply for one of CDC’s approx- imately 3,600 School Culture Wellness ■ Steps to a Healthier U.S.: The Steps to a Grants to help implement action plans. Healthier U.S. program funds communities FY 2008 Presidential Appropriations Request for CDC Programs & Divisions Division/Program FY 2007 President FY 2008 Difference in Funding Proposal (FY08-FY07) Division of Nutrition, Physical $41,351,000 $41,309,000 ($42,000) Activity, and Obesity (DNPAO) Division of Adolescent School Health (Note: $55,949,000 $55,893,000 ($56,000) this includes funds for HIV programs)142 Steps to a Healthier U.S. $43,685,000 $26,386,000 ($17,299,000) Adolescent Health Promotion Initiative $0 $17,300,000 $17,300,000 48 E. ACCELERATING RESEARCH ON EFFECTIVE OBESITY REDUCTION AND CONTROL While there is a lot of scientific evidence about gies for preventing and controlling weight the benefits of nutrition and physical activity gain should be greatly accelerated. on health, there are few studies that have In past editions of F as in Fat, TFAH has iden- found effective, long term, community-based tified research questions that should be prior- strategies for obesity prevention. Evaluations itized to enhance the ability of public health of the current body of research call for addi- officials to respond to the crisis. These ques- tional resources for “translational” research to tions are included in the Recommendations help inform and improve long term, commu- section of this report. nity-based approaches. While this “translational” research is critical to NIH, CDC, HRSA, and other HHS agencies success in the long term, the nation cannot wait have research efforts underway to try to for the outcomes of this research to ramp up inform improved obesity prevention and efforts to combat obesity. The impact of obesi- control efforts, particularly through finding ty on the current population and the continu- more effective ways to encourage behavior ing rise of obesity rates, particularly in children, change. requires the nation to take action now, based Given the epidemic proportion of the obesi- on the best evidence and practices currently ty crisis, research into evidence-based strate- known, while more research is conducted. OVERVIEW OF NIH OBESITY RESEARCH In 2004, NIH released a Strategic Plan for NIH Below are a few examples of research Obesity Research, “a multi-dimensional projects NIH has funded recently under research agenda to enhance both the develop- the 4 major scientific themes of its strate- ment of new research in areas of greatest sci- gic plan for obesity research. entific opportunity and the coordination of obe- ■ HEALTHY -- A Middle School-Based sity research across NIH.”143 Study To Reduce Risk Factors for Type 2 In FY 2006, the National Institute of Diabetes and Diabetes in Children, a study to determine Digestive and Kidney Diseases (NIDDK), which whether changes in school food services and is the lead institute dealing with obesity at NIH, physical education classes, along with activi- awarded $305,102,358 in funding for obesity- ties that encourage healthy behaviors, lower related research projects. That same fiscal year, risk factors for type 2 diabetes in youth.148 the National Heart, Lung, and Blood Institute ■ Look AHEAD (Action for Health in (NHLBI) of NIH awarded $102,188,764 in fund- Diabetes), a clinical trial about the health ing for obesity-related research projects.144 effects of an intensive lifestyle intervention There is concern that the Administration’s FY designed to achieve and maintain weight loss 2008 budget proposal calls for a $328 million over the long term, through decreased reduction in funding for the NIH, which caloric intake and increased physical activity.149 would lead to a reduction in research grants ■ Trial of Activity in Adolescent Girls for obesity and physical activity related topics (TAAG), a group randomized trial of a in the near future. school- and community-based physical Some of NIH’s Calls for Research have activity intervention to prevent the decline included studies focusing on: in physical activity of adolescent girls.150 ■ Preventing and treating childhood obesity ■ Girls Health Enrichment Multi-Site in primary care settings;145 Studies (GEMS), a program of 4 studies to ■ The relationship between obesity and the develop and test interventions to prevent built environment; and146 obesity by decreasing weight gain in high- ■ Ways of improving workplaces to promote risk, African American, pre-adolescent girls.151 health and reduce obesity.147 49 Promoting Physical Activity as a Strategy to Improve Health 4 SECTION O besity reduction and prevention efforts often focus on encouraging people to eat healthier and take part in more physical activity. Experts agree that a more nutritious diet and to engage in healthier behaviors whether or taking part in physical activity are good for not they are overweight.153 everyone, regardless of their current weight. While there is little support for effective, The challenge is how to make it easier for long term approaches to successful weight people to make healthy choices, and what loss, there is significant scientific consensus specific actions to recommend when the around the health benefits of physical activ- majority of Americans are not doing what ity for everyone, no matter their weight. the experts recommend, despite warnings it According to studies, for individuals who could hasten disease and death. are overweight or obese, any amount of weight that might be lost through this A recent review of strategies to prevent, con- increased activity is also beneficial to a per- trol, and treat obesity, funded in part by NIH, son’s health, even if it is in smaller amounts. found that adult weight-loss centered strategies often yield limited results, and successes are Encouraging increased physical activity is “typically small and tend to be transitory.”152 not about expecting people to become Another review found that “a focus on weight major athletes or strive for unrealistic fitness loss is often counterproductive and unsuccess- goals, but about getting everyone to become ful, and sometimes may even be unnecessary,” active to achieve health benefits, no matter compared to focusing on encouraging people what their fitness level may be. 51 TRENDS IN PHYSICAL ACTIVITY Adults: ■ Currently, more than 22 percent of adult Americans say they do not engage in any physical activity.154 ■ More than half of adults report they do not participate in CDC’s recommended level of physical activity, which includes either 30 minutes or more of moderate physical activity 5 or more days per week, or 20 minutes or more of vigorous physical activity for 3 or more days per week.155 The minimum level of recommended activity is equivalent to walking 2 miles at a pace of 3 to 4 miles per hour.156 ■ Sixty percent of adults are not sufficiently active to achieve health benefits. ■ Participating in leisure time physical activity declines as age increases. ■ Women are less likely to engage in moderate or vigorous physical activity. ■ African American and Hispanic adults are less likely to be physically active than white adults.157 Youth: ■ Nearly 10 percent of high school students do not regularly participate in vigorous or moderate physical activity, and only 54 percent of high school students had physical education class at least once a week and only 33 percent had daily physical education.158 ■ More than 35 percent of high school students participated in vigorous activity for more than 60 minutes 5 days during a week.159 ■ Nearly 70 percent of high school students participated in CDC’s recommended minimum level of activity for youth, which includes at least 20 minutes of vigorous activity or 30 minutes of moderate activity for 3 or more days during a week. ■ More than 20 percent of high school students played video or computer games or used a com- puter for something other than school work for 3 or more hours on an average school day. ■ More than 35 percent of high school students watched 3 or more hours on an average school day. This section focuses on physical activity as a separate the 2 issues or isolate findings, and, key strategy for helping improve the health therefore, they are discussed together within of Americans. It examines: this section. Recently, more research is begin- A. Physical Activity and Health; ning to examine physical activity independ- ently to be able to provide more robust infor- B. Economic Costs of Physical Inactivity mation about the health impact of and ways to and Obesity; better encourage increased physical activity. C. Current Recommendations for Physical Activity; Developing strategies for encouraging increased physical activity requires the D. Barriers to People Engaging in Enough involvement of a range of sectors, such as Physical Activity; and schools, community developers, and work- E. Public Health Strategies for Encouraging places. Effective approaches will require Increased Physical Activity public health officials to reach out beyond Physical activity and weight are obviously close- the traditional health community to involve ly related. In many of the studies, it is hard to a wide range of stakeholders. 52 NUTRITION: THE OTHER SIDE OF THE ENERGY BALANCE There is obviously a lot of evidence about what constitutes good nutrition. Both physical activity and nutrition influence a person’s weight. TFAH chose to concentrate on physical activity for this report. However, just like with physical activity, research has also found that improved nutrition has a positive effect on people’s health no matter how much they weigh. According to an article pub- lished by the National Institute for Health Care Management, “for most Americans, a healthy diet means: smaller portions (fewer calories, minimal saturated and ‘trans’ fats, few sweets) and low fiber carbohydrates (think desserts and sodas), and more fruits and vegetables).”160 Efforts to encourage people to change eating habits are as complex as trying to motivate people to be more physically active. Some changes to the eating habits of Americans over the past few decades include:161 ■ More calories ▲ Adults consumed approximately 300 more calories daily in 2002 than they did in 1985.162 ▲ Women ages 20-74 consumed nearly 22 percent more calories in 1999-2000 than they did in 1971-74; men consumed nearly 7 percent more calories.163 ▲ Adolescent females ages 12-15 consumed approximately 4 percent more calories in 1999- 2000 than they did in 1971-74; 16-19 year olds consumed approximately 15 percent more.164 ■ Bigger portion sizes ▲ A study in the Journal of the American Medical Association examined the rise in portion sizes and found that from 1977-1998, portion sizes for selected popular food items and overall energy intake have increased for foods purchased in restaurants or fast food establishments and for foods prepared in the home, with an increase of between 49 and 133 calories for all selected popular food items except for pizza, such as salty snacks, hamburgers, soft drinks, french fries, and Mexican food.165 ■ Fewer fruits, vegetables, and whole grains ▲ A 2003 USDA report examining Americans food consumption patterns called America’s per capita fruit consumption “woefully low” and is limited to a small range of fruit options, and that vegetable consumption “tells the same story.”166 ▲ Per capita grain consumption has risen nearly 50 percent since the early 1970s, but whole grain consumption has dropped.167 ■ More sugar ▲ “Added sugar” consumption is nearly 3 times the USDA recommended intake.168 ▲ Average consumption of added sugars increased 22 percent from the early 1980s to 2000. 169 ■ More dietary fat ▲ Americans consumed an average of 600 calories worth of added fats per person per day in 2000.170 ■ A drop in drinking milk and a large increase in drinking soda and fruit juice ▲ Milk consumption dropped 39 percent from 1977 to 2001 for children ages 6-11 while con- sumption of soda rose 137 percent, fruit juice rose 54 percent, and fruit drinks rose 69 percent.171 ■ A major increase in eating out ▲ In 1975, approximately 25 percent of food spending was in restaurants; by 1995, this had risen to 40 percent. ▲ Spending in fast food restaurants grew 18 times (from $6 billion to $110 billion) in the past 3 decades. ▲ In 1970, there were approximately 30,000 fast food restaurants in the U.S.; in 2001, there were approximately 222,000. ▲ Children ate out at fast food and other restaurants nearly 3 times more in 1996 than they did in 1977. 53 A. PHYSICAL ACTIVITY, HEALTH, AND LONGEVITY “Regular physical activity that is performed Experts have found that: on most days of the week reduces the risk of ■ Physical activity helps control and prevent developing or dying from some of the lead- a range of health problems, including dia- ing causes of illness and death in the United betes, heart disease, and stroke; and States,” according to the Office of the ■ Even small amounts of physical activity can Surgeon General.172 improve health, no matter how much a per- son weighs or whether a person loses weight. 1. Physical Activity and Preventing and Controlling Health Problems Physical activity has been found to reduce the ity and double the risk of cardiovascular dis- risk of dying prematurely, dying prematurely ease, obesity, and type 2 diabetes.”182 from heart disease, developing diabetes, Physical activity can also help people better developing high blood pressure, and reduces manage diseases they already have, such as type already high blood pressure and the risk of 2 diabetes.183 Individuals with type 2 diabetes developing colon cancer. It also helps con- have an increased risk for heart disease and trol weight; build and maintain healthy stroke. In fact, 75 percent of all deaths in type bones, muscles, and joints; helps older adults 2 diabetic patients are attributable to heart dis- become stronger and better able to move ease and stroke.184 However, a 2005 study in about without falling; and promotes psycho- Diabetes Care found that active adults with type logical wellbeing.173, 174, 175, 176, 177, 178, 179, 180, 181 2 diabetes had 40 percent less risk of death A 2004 article in Critical Pathways in Cardiology from heart disease and stroke compared to concluded that “of all U.S. deaths from major sedentary adults with type 2 diabetes.185 chronic disease, 23 percent are linked to Currently, it is estimated that only 28.2 percent sedentary lifestyles,” and that generally of non-disabled adults with diabetes participate “sedentary lifestyles increase all-cause mortal- in the recommended level of physical activity.186 CHILDREN AND PHYSICAL ACTIVITY AND PREVENTING AND CONTROLLING HEALTH PROBLEMS Recent studies have demonstrated that physical inactivity can also lead to poorer health out- comes in children and adolescents.187, 188, 189, 190, 191 Physical inactivity is tied to heart disease and stroke risk factors in children and adolescents.192 And according to studies by NIH and CDC, physical inactivity can lead to increased risk of insulin resistance and the eventual development of diabetes and heart disease in children and adolescents.193, 194 2. All Forms and Amounts of Physical Activity Are Beneficial to Health Studies have found that even small amounts ease or type 2 diabetes.196,197 For instance, a of physical activity help to reduce the risk of 1999 study found that women who either death and disease in adults.195 walked briskly for 1.5 hours per week or swam laps for 45 minutes per week reduced their risk In addition, studies find that both vigorous and of a non-fatal heart attack or death due to coro- non-vigorous (e.g., walking) physical activities nary disease by around 90 percent.198 Walking can lead to similar positive health outcomes in is a widely accessible physical activity, can be adults, such as a reduction in risk of heart dis- 54 readily adopted, and is rarely associated with tinuous period.200,201 For example, a 2002 study physical activity related injury.199 found that “three short bouts (10 minutes) of brisk walking accumulated throughout the Accumulating physical activity in short peri- day are at least as effective as one continuous ods is also found to be as beneficial to health, bout of equal duration in reducing cardiovas- as accumulating physical activity in one con- cular risk” in previously sedentary adults.202 HEALTH IMPACT OF OBESITY AND PHYSICAL INACTIVITY Below are some key findings based on a range of research into the health impact of obesity. Physical activity has been shown to have a role in reversing or preventing many of these health problems. ■ Type 2 Diabetes ▲ More than 80 percent of people with type 2 diabetes are overweight.203 ▲ More than 20 million adult Americans have diabetes.204 ▲ Another 54 million Americans are pre-diabetic, which means they have prolonged or uncon- trolled elevated blood sugar levels that can contribute to the development of diabetes.205 ▲ Diabetes is the sixth leading cause of death in the U.S. and accounts for 11 percent of all U.S. health care costs.206 ▲ CDC projects that 48.3 million Americans will have diabetes by 2050.207 ▲ Approximately 176,500 individuals under the age of 20 have diabetes.208 ▲ Two million adolescents (or 1 in 6 overweight adolescents) aged 12-19 have pre-diabetes.209 ■ Heart Disease and Stroke ▲ People who are overweight are more likely to suffer from high blood pressure, high levels of blood fats, and LDL (“bad”) cholesterol -- all risk factors for heart disease and stroke.210 ▲ Heart disease is the leading cause of death in the United States, and stroke is the third leading cause.211 ▲ One in 4 Americans has some form of cardiovascular disease.212 ▲ Heart disease can lead to a heart attack, congestive heart failure, sudden cardiac death, angina (chest pain), or abnormal heart rhythm.213 ▲ A stroke limits blood and oxygen to the brain and can cause paralysis or death.214 ▲ More than 75 percent of hypertension cases are reported to be directly attributed to obesity.215 ■ Cancer ▲ People who are overweight “may increase the risk of developing several types of cancer, including cancers of the colon, esophagus, and kidney. Overweight is also linked with uterine and postmenopausal breast cancer in women.”216 ▲ Approximately 20 percent of cancer in women and 15 percent of cancer in men is attributable to obesity.217 ▲ Cancer is the second leading cause of death in the United States.218 ▲ It is unknown why being overweight can increase cancer risk. One theory is that fat cells may affect overall cell growth in a person’s body.219 ■ Unhealthier Earlier in Life ▲ Research has found younger adults who are obese may face greater health risks earlier in life. For instance, a 2005 study found that women who were obese at age 30 were more likely to die at a younger age and significantly more likely to develop cancer.220 ▲ Some research suggests obesity in middle age may put individuals at higher risk for developing dementia later in life.221 55 PSYCHOSOCIAL AND HEALTH CONSEQUENCES OF OBESITY IN CHILDHOOD AND ADOLESCENCE A number of studies have documented how children who are obese typically remain obese as adults. This research stresses how obesity increases a child’s risk for a number of health problems, including the emerging onset of type 2 diabetes, increased cholesterol and hypertension among children, and the danger of eating disorders among obese ado- lescents.222 Research suggests that individuals diagnosed with diabetes before age 20 have a life span 15 to 27 years shorter than non-diabetic Americans, and that the earlier the onset of diabetes, the higher the incidence of nephropathy, retinopathy, neuropathy, and coronary and peripheral vascular disease.223 Youth overweight may also lead to orthopedic ailments and premature onset of menstruation.224 Some studies show that obesity and overweight in children also negatively impacts children’s mental health and school performance.225 Overweight children have been found to engage in other unhealthy behaviors and tend to show loneliness and nervousness.226 The studies also emphasize that obesity and overweight in childhood and adolescence are often a pathway toward increased risk and further development of a range of obesity-related diseases as they enter adulthood, leading to a lifetime of health problems. MATERNAL OBESITY AND BIRTH DEFECTS Research has found that a woman’s weight impacts both the health of the mother and child.227, 228 Twenty-six percent of non-pregnant women 20-39 years old are overweight and 29 per- cent are obese, according to estimates.229 Compared with normal-weight women, obese women are found to be 50 percent more like- ly to have post-delivery bleeding; twice as likely to deliver prematurely; and are more likely to need an emergency C-section or to have labor induced.230 Women who are overweight or obese prior to pregnancy are at an increased risk of having a child with birth defects.231 ■ Obese women are more likely to have an infant with spina bifida or other neural tube defects compared to normal weight women.232 In infants with spina bifida, the neural tube (which develops into the brain and spinal cord) does not close completely and, as a result, defects in the spinal cord and in the vertebrae of the spine can occur.233 ■ Obese women are more likely to have an infant with omphalocele compared to normal weight women.234 Omphalocele is a birth defect “in which the infant’s intestine or other abdominal organs stick out of the belly button.”235 ■ Both obese and overweight women are more likely to have an infant with heart defects compared to normal weight women.236 While the reasons for birth defects in infants of obese mothers are largely unknown, some researchers speculate that: 1) obese mothers may have elevated insulin or estrogen levels that increase their risk for birth defects;237 2) obese mothers are more likely to have diabetes, which is a known risk factor for birth defects;238 or 3) obese women may “have nutritional deficits, resulting from dieting behaviors or poor-quality diets,” which increase their risk for birth defects.239 Regardless of what factors are involved, experts recommend that obesity intervention and prevention efforts focus on increasing “the number of women who are of healthy weight before pregnancy.”240 56 OBESITY AS A POSSIBLE RISK FACTOR FOR DEMENTIA AND ALZHEIMER’S DISEASE There is growing evidence that obesity and diabetes are associated with certain neurological diseases.241, 242, 243 Additionally, physical activity is now recommended for both primary and sec- ondary prevention of some conditions. A number of studies have examined the link of obesity with Alzheimer’s disease.244 Researchers have long believed that Alzheimer’s disease is correlated with diabetes. Recently, however, sci- entists have begun to establish that obesity is also a high risk factor, even before an individual may get diabetes. An obese individual produces more and more insulin to try and lower blood sugar levels. High insulin levels lead to the inflammation of blood vessels, including those in the brain. The inflammation can cause the body to send off chemical warning signals, which may damage tissues. For example, insulin-induced brain inflammation may lead to increased brain levels of the protein beta-amyloid.245 Beta-amyloid is an important part of the sticky plaques that clog the brains of people, and can lead to dementia and Alzheimer’s disease. ■ In a 2007 review of previous studies looking at a potential link between dementia and obe- sity, researchers concluded that increased excessive weight (measured as BMI) “is inde- pendently associated with increased risk of dementia.”246 ■ A 2005 study in BMJ found that obese adults had a 74 percent greater risk of dementia compared to normal weight adults, while overweight adults had a 35 percent greater risk of dementia.247 ■ A 2005 study in the Archives of Neurology concluded that “obesity at midlife is associated with an increased risk of dementia and AD [Alzheimer’s Disease] later in life.”248 Controlling obesity and focusing on exercise and healthy eating are now recommended preven- tive measures for Alzheimer’s disease, similar to activities to control heart disease and cancer. According to Dr. Samuel Gandy, Chairman of the Alzheimer’s Association’s medical and scientific advisory committee and director of the Farber Neuroscience Institute at Thomas Jefferson University, Philadelphia: “Controlling blood sugar and body weight -- all those things we know are good for your heart health are also really good at preventing Alzheimer’s disease. So there are more and more reasons not to be slouchy about getting these things under control.”249 Some experts express concern that increasing rates of obesity could lead to a continued rise in Alzheimer’s in the future, and that the rise in obesity at younger ages could contribute to increased cases of early-onset Alzheimer’s. ALZHEIMER’S RATES EXPECTED TO GROW EXPONENTIALLY Dementia is when brain cells are gradually destroyed, leading to a decline in mental function. Alzheimer’s disease, mostly found in older adults, is the most common form of dementia.250 According to the Alzheimer’s Association, more than 5 million people in the U.S. current- ly have Alzheimer’s disease, including:251 ■ 4.9 million people over the age of 65; and ■ Between 200,000 and 500,000 people under the age of 65 who have developed early- onset Alzheimer’s and other dementias. These rates are expected to rise dramatically in the future.252 ■ It is estimated that the number of people ages 65 and over suffering from Alzheimer’s will increase to 7.7 million by 2030, a greater than 50 percent increase over the current number of individuals affected by the disease. ■ And “unless science finds a way to prevent or effectively treat” Alzheimer’s, it is estimated that the number of individuals over the age of 65 who are afflicted with the disease could range between 11 million and 16 million by 2050.253 57 B. THE HIGH ECONOMIC COSTS OF PHYSICAL INACTIVITY AND OBESITY Economists and health experts have exam- physical inactivity costs $128 per person in ined how much physical inactivity and obe- the U.S. annually.259 A 2004 study found sity are adding costs to the nation’s health there were 9.2 million cases of cardiovascu- care system. According to HHS, obese and lar disease resulting in $23.7 billion in direct overweight adults cost the U.S. anywhere medical expenditures associated with physi- from $69 billion to $117 billion per year.254 cal inactivity in 2001.260 ■ More than a quarter of U.S. health care Studies have also estimated that health care costs are related to physical inactivity, costs could be reduced with increased phys- overweight, and obesity.255 ical activity. For instance, one study found: ■ A 2004 study in Health Affairs found that ■ If one tenth of Americans began a regular 27 percent of the increase in health care walking program, $5.6 billion in heart dis- spending between 1987 and 2001 was ease costs could be saved; related to the rise in obesity rates and ■ Sedentary Americans spend $330 more in higher relative cost of health care spend- direct healthcare costs than active ing for people with obesity.256 Americans (1987 dollars);”261 ■ Between 1979 and 1999, obesity-associat- A Canadian study found that if 10 percent ed hospital costs for children (ages 6 to 17 fewer British Columbians were physically years) more than tripled, from $35 mil- inactive (i.e. if the rate of physical inactivity lion to $127 million.257 dropped from 38 percent to 34.2 percent), ■ Obese individuals 55 and older had higher the province could save an estimated $18.3 annual expenses for medical care as com- million every year in avoided hospital, drug, pared with normal weight and overweight physician, and other direct costs.262 individuals, according to a 2002 study by Studies have found that obese and physical- the Agency for Healthcare Research and ly inactive workers are not just associated Quality. The breakdown was $7,235 for with higher costs for individual care but also obese, $5,478 for overweight, and $5,390 higher health care costs for businesses; for normal weight persons.258 lower worker productivity and increased absenteeism; and higher workers’ compen- Other studies have tried to isolate the costs sation claims. of physical inactivity. A 1999 study found 58 HIGHER HEALTH CARE COSTS FOR BUSINESSES ■ On average, obese workers have up to 21 percent higher health care costs compared to normal weight employees. It is estimated that in 1994, obesity cost U.S. businesses $12.7 billion, of which physical inactivity accounted for $7.7 billion.263 ■ In 2000 alone, physically inactive members cost Blue Cross and Blue Shield of Minnesota (BCBSMN) a total of $83.6 million (or $56 for every member) per year. In addition, “almost one third (31 percent) of costs related to heart disease, stroke, colon cancer, and osteoporosis” in the BCBSMN population were attributable to physical inactivity.264 ■ Higher health care costs for obese and sedentary workers signal poorer overall health among these individuals. And given poorer health, lower worker productivity and increased absenteeism are more likely among obese and physically inactive employees. Lower Worker Productivity and Increased Absenteeism ■ Researchers found that obese workers had 183.63 lost workdays per 100 full time employees, compared to normal weight workers who had 14.19 lost workdays per 100 full time employees.265 ■ A 2004 study concluded that excessive weight and physical inactivity negatively impact the quality of work performed, the quantity of work performed, and overall job performance among obese, sedentary individuals.266 Higher Workers’ Compensation Claims ■ A number of studies have shown obese workers have higher workers’ compensation claims.267, 268, 269, 270, 271, 272 ■ A 2007 study found that excessive weight gain among employees is related to higher amounts of workers’ compensation claims.273 Obese workers had on average 11.65 claims per 100 full time employees, compared to normal weight employees who had 5.80 claims per 100 full time employees.274 ■ The cost of claims for obese employee workers’ compensation claims were also significantly higher. Obese employees had $51,091 in medical claims costs per 100 full time employees, compared to only $7,503 in medical claims costs for normal weight workers. And obese workers had $59,178 in indemnity claims costs per 100 full time employees, compared to only $5,396 in indemnity claims costs for normal weight employees.275 59 GENERAL MOTORS: WAISTLINE IMPACTING BOTTOM LINE General Motors (GM) provides an example of the major burden obesity and physical inactivity can exact on companies and their bottom line. GM is one of many auto companies that finds health costs of workers and retirees is a top issue in union negotiations. ■ Twenty-six percent of GM’s 1.1 million union beneficiaries are obese.276 ■ Obesity cost the company $286 million in 2004 alone.277 ■ Of the $5.3 billion GM spent on medical costs in 2005, an estimated 25 percent was due to unhealthy habits such as overeating, lack of exercise, cigarettes, and alcohol.278 ■ A 2003 study found that among GM beneficiaries (employees, retirees, and their adult dependents), extremely obese (BMI≥ 40) individuals had annual median medical costs of $3,753, compared to normal weight individuals (18.5≤ BMI≤ 24.9) who had annual median medical costs of $2,225 (a striking difference of $1,528).279 Overall, annual median medical costs increased as BMI level of beneficiaries grew (see graph below). In response to the economic burden obesity and physical inactivity exacts on the company, GM created LifeSteps, “the nation’s largest employer-sponsored wellness program.” The pro- gram includes employee access to online health information, free health screenings, and other prevention-oriented benefits. The LifeSteps program has lowered GM’s medical costs by $27 million.280 But given that obesity alone cost the company $286 million in 2004, health costs of its employees remains a major factor in the company’s bottom line and its ability to remain competitive with other automakers, particularly foreign automakers. 60 ECONOMIC BURDEN OF OBESITY AND PHYSICAL INACTIVITY ON MEDICARE AND MEDICAID A study found obese Medicare patients annual expenditures were 15 percent higher than normal or overweight patients.281 A 2003 article in Health Affairs estimated that Medicare and Medicaid alone financed approximately half of the nation’s overweight- and obesity-related costs.282 A 2004 study found that individuals who were severely obese earlier in life had total average annu- al Medicare expenditures of $12,342 later in life, compared to individuals who were normal weight earlier in life who had annual average Medicare expenditures of $6,224, a difference of $6,118.283 The weight categories in the chart above refer to the following BMI levels: 18.5-24.9 (non-overweight); 25.0-29.9 (overweight); 30.0-34.9 (obese); and ≥ 35.0 (severely obese). OBESITY COSTS IN KAISER PERMANENTE PATIENTS Two studies examining patient populations within the Kaiser Permanente Colorado health care system found that the difference in health care costs between obese and non-obese patients was substantial for adults, children and adolescents. ■ For adults, the median annual expenditure of obese patients was $585.44, compared to $333.24 for non-obese patients (a difference of $252.20).284 ■ Annual health expenditures for an overweight child were $72 higher than for a healthy-weight child. With approximately 6,500 child members of Kaiser Colorado who are overweight, this per child increase translates into “almost half a million dollars” more per year for the insurer.285 These costs are expected to increase as the children age and develop increased health problems. 61 C. CURRENT RECOMMENDATIONS FOR PHYSICAL ACTIVITY CURRENT RECOMMENDED LEVELS OF PHYSICAL ACTIVITY FOR ADULTS According to the Dietary Guidelines for Americans, 2005, adults should:286 ■ Engage in regular physical activity and reduce sedentary activities to promote health, psy- chological well-being, and a healthy body weight. ▲ To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of moderate- intensity physical activity, above usual activity, at work or home on most days of the week. ▲ For most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or longer duration. ▲ To help manage body weight and prevent gradual, unhealthy body weight gain in adult- hood: Engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements. ▲ To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily moderate- intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with a healthcare provider before participating in this level of activity. ■ Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance. According to August 2007 recommendations from the American Heart Association and American College of Sports Medicine, healthy adults should:287 ■ Engage in moderate-intensity aerobic physical activity for at least 30 minutes 5 days each week, or vigorous-intensity aerobic exercise for at least 20 minutes 3 days a week. ▲ Moderate-intensity aerobic activities can include a brisk walk, light jogging or other exer- cise that accelerates the heart rate. Vigorous-intensity exercise like jogging causes rapid breathing and a substantial increase in heart rate. ■ Engage in weightlifting exercise to work on muscular strength and endurance, with 8 to 10 different exercises on 2 nonconsecutive days a week. The guidelines state that exercise above the minimum amounts can provide even greater health benefits. People 65 and older are urged to consider lifting weights to improve their strength to prevent falls, and working on flexibility exercises and balance training. CURRENT RECOMMENDED AMOUNT OF PHYSICAL ACTIVITY FOR CHILDREN AND YOUTH Sixty minutes, according to the Dietary Guidelines for Americans, 2005, published jointly by HHS and USDA. Specifically, “it is recommended that children and adolescents participate in at least 60 minutes of moderate intensity physical activity most days of the week, preferably daily.”288 NEW FEDERAL PHYSICAL ACTIVITY GUIDELINES TO BE RELEASED IN 2008 In October 2006, HHS announced that it will develop science-based physical activity guide- lines for Americans. The guidelines will be released in late 2008 and will target specific sub- populations, such as children, the elderly, and the disabled. According to HHS, a major goal of the guidelines is to help instigate a cultural shift in American society from one that focuses on treatment to one that values prevention of disease through healthy choices and behaviors, such as increased physical activity. “Changing the culture from one of treating sickness to staying healthy calls for small steps and good choices to be made each and every day,” HHS Secretary Mike Leavitt said. “These phys- ical activity guidelines will encourage the creation of a culture of wellness across America.”289 62 D. BARRIERS TO PEOPLE ENGAGING IN ENOUGH PHYSICAL ACTIVITY A wide range of factors influence how phys- ■ Communities Not Designed for Physical ically active individuals are. Some addition- Activity al barriers that deter people engaging in ▲ Communities development paves the physical activity include: way for driving more often than walk- ■ Limited Time ing or biking ▲ Long work and school hours ▲ Lacking or limited public transportation ▲ Long commuting time and time spent ▲ Poor upkeep of sidewalk infrastructure in cars ▲ Walking areas are often unsafe or inconvenient ■ Family and Home Influences ▲ Limited parks and recreation space, ▲ Influence of other family members including indoor facilities habits and priorities ▲ Poor upkeep and security in local parks ▲ “Electronic culture” options for enter- tainment and free time, including TV, ▲ Weather conditions limit outdoor phys- video games, and the Internet ical activity options and lack of afford- able indoor physical options ■ Children and Schools ■ Economic Constraints ▲ Reduction in the amount of physical education, recess, and recreation time ▲ Health insurance coverage to encour- age physical activity, such as subsidized ▲ Lack of quality measures for physical gym memberships is often limited or education classes not available ▲ Lack of non-competitive intramural ▲ People without health insurance often and physical activity clubs accessible to do not receive appropriate preventive all students services or post-condition treatments ■ Workplaces Not Conducive to Health ▲ Costs of gym memberships, exercise ▲ Many workplaces do not offer work- classes, equipment, facility use, and place wellness programs sports league fees ▲ Many desk jobs where activity is limited ■ Psychology or not encouraged ▲ Fears and frustrations can deter some ▲ Worksites typically are not designed to people from physical activity foster movement ▲ Lack of support from family and friends ▲ Limited opportunities for physical ▲ Self consciousness about working out activity or recreation during the day in front of others ■ Lack of Awareness or Knowledge ▲ Limited information about how to engage in beneficial amounts of physical activity 63 E. PUBLIC HEALTH STRATEGIES FOR ENCOURAGING INCREASED PHYSICAL ACTIVITY Public health experts have determined a num- 1. Family-based Approaches; ber of promising intervention strategies for 2. School- and Before and Afterschool-Based trying to help make it easier for people to Approaches; decide to increase the amount of physical 3. Community-Based Approaches; activity they take part in. A combination of all of these efforts is considered important for 4. Health Care Provider-Based Approaches; promoting increased physical activity and pre- 5. Workplace and Insurance-Based venting obesity. This section examines a range Approaches; and of current trends and approaches, including: 6. Impoving the Built Environment. 1. Family-based Approaches A review of a range of studies found that fam- loss of a loved one or relative; encourage- ily-based strategies that target working with ment or advice from family or friend; new parents and children together are some of illness or death of a high-profile “celebrity” the most effective ways to encourage behav- or public figure; health education messages. ior change and can “produce significant A wide range of policies can impact deci- long-term results.”290 Parental influence is sions individuals make. For instance, poli- shown to be strong, particularly on younger cies related to maternity and paternity leave, children. Experts believe family-based flexible work hours, income, sick and leave approaches are most effective when children time, and availability of work-site daycare all are young, “before obesity-promoting behav- impact the amount of time people have to iors have become well ingrained.”291 Parents engage in physical activity and for parents to can provide positive behavior to model, work spend with their children and can supervise to ensure the family has time and places to or be supportive of healthy living patterns. engage in physical activity, and encourage In addition, the cost, availability, and safety children to engage in physical activity with of recreational space and gyms impact deci- their peers. sions people make about physical activity. Family members may find interventions at Individuals and families can impact deci- key moments can be most effective. A 2004 sions that businesses and policymakers article by Bernard E. Bulwer, MD, MSc, out- make about these policies. People have lined “trigger factors” that can lead to life leverage as voters and consumers. They can changes in behavior:292 Trigger factors he directly communicate with policymakers identified include, development of a new ill- about policies, with employers about bene- ness; doctor’s orders; failed medical check- fits, and with the food and beverage indus- up or abnormal laboratory report; illness or try by supporting healthier products. 2. School-based and Before- and After School-Based Approaches Child care, schools, and before and after “Call to Action” issued by the U.S. Surgeon school programs provide strong environ- General. And, a study by the Government ments for reaching children. Accountability Office found that experts rank “increasing physical activity” as the School-based approaches were identified as most important strategy for preventing or key to addressing overweight, obesity, and reducing childhood obesity.293 physical activity in children and youth in a 64 Experts emphasize that both formal physical This allows for different school districts to education classes and scheduled recess or try a range of different approaches, but it other free time to engage in physical activity also makes establishing uniform standards during the day are important components of or guidelines and measuring change a seri- the strategy to increase regular movement by ous challenge. In addition, many policies schoolchildren and youth. Before and after- and recommendations are set without finan- school programs provide additional venues cial support to implement them. for encouraging physical activity. Also, many education agencies argue that Every state requires some physical education physical education policies are often not for students. However, physical education enforced because there are already too many requirements do not extend to all grade lev- other mandated curriculum requirements. els and are often not enforced. And of the Some education experts point out that the programs that do exist, many of them are Elementary and Secondary Education Act inadequate with respect to quality. (ESEA), known as the “No Child Left Behind Act,” which emphasizes student achievement Many states are considering ways to improve on standardized tests, is forcing school dis- and better implement physical education tricts to divert limited resources away from requirements. programs that are not tested, like physical However, there are more than 14,000 school education and extracurricular sports.294 districts in the U.S. and the primary juris- Only 54 percent of high school students had diction for most school policies is the school physical education class at least once a week district. While the federal government and and only 33 percent had daily physical educa- states set policies or recommendations, local tion in 2005.295 Fifty-six percent of high school jurisdictions may have discretion to decide students played on one or more sports teams, whether or not to follow federal or state either through school or community groups.296 directed guidelines. RECOMMENDATIONS FOR PHYSICAL EDUCATION AND PHYSICAL ACTIVITY FOR CHILDREN ■ The CDC considers children “meeting recommended levels of physical activity” as 60 minutes or more of activity per day on five or more days per week in the survey of youth behavior.297 ■ The National Association for Sports and Physical Education recommends that schools pro- vide 150 minutes of instruction physical education for elementary school children, and 225 minutes for middle and high school students per week for the entire school year.298 ■ The American Heart Association recommends creating requirements for all students in grades K-8 (including students with disabiling conditions and in alternative education pro- grams) to participate in daily physical education for the entire school year. They recom- mend a minimum standard of at least 150 minutes during each school week for elementary students and at least 225 minutes per week for middle school students.299 FEDERAL GUIDELINES TO HELP PROMOTE PHYSICAL ACTIVITY Schools and communities have the potential to improve the lifelong health of the next genera- tion by providing instruction and programs in physical education. To guide the effort, the CDC, together with partners in other federal agencies and health organizations, developed “Guidelines for School and Community Programs to Promote Lifelong Physical Activity Among Young People.” The guidelines recommend comprehensive, daily physical education for students beginning in kindergarten through grade 12.300 65 CAROL M. WHITE PHYSICAL EDUCATION PROGRAM (PEP) GRANTS The Carol M. White Physical Education Program (PEP) is a federal program that awards grants to local educational agencies and community-based organizations (including faith-based organizations) to initiate, expand, and improve physical education programs (including after school programs) for students in one or more grades from kindergarten through 12 in order to make progress toward meeting State standards for physical education.301 PEP was created in 2001 through the reauthorization of the No Child Left Behind Act and is administered by the U.S. Department of Education. PEP grants can be used for equipment, support, and the training and education of teachers and staff.302 PEP has grown in overall funding and the number of grants it awards to local educational agencies and organizations. During its initial year, $5 million dollars was awarded to 18 school districts. Fifty million dollars in funding was awarded to 176 recipients in 2002 and $60 million dollars was allocated to 256 grant winners in 2003. Seventy million dollars was awarded to 237 grantees in 2004 and $74 million was distributed to 104 recipients in 2005. Overall fund- ing for the program was at $72.6 million in 2006.303 A number of PEP grants have been awarded to physical education (P programs established by .E.) PE4Life, a non-profit organization dedicated to inspiring active and healthy lifestyles in all children, not just those that are athletically inclined. PE4Life believes in a new model of P in which students .E. are evaluated on whether they have achieved personal physical activity and fitness goals, rather than being judged on overall sports skills (e.g., how well a student plays a specific sport such as softball or soccer) and athletic performance (e.g., whether a student can run an eight-minute mile).304 For example, one PE4Life program located at Naperville Central High School in Naperville, Illinois, offers students an array of opportunities to meet their daily physical activity requirement, including square dancing, scaling a climbing wall, or using exercise bikes that simulate raceways and ski slopes. They wear heart monitors to assess their physical activity effort and learn about nutrition and measure their BMI to ensure their height is in proportion to their weight.305 In addition to in-school activity, studies find only a high school degree, and children age 9 declining rates of physical activity in children were less likely than those between the ages of and youth before and after school. Thirty 11 and 13 to bike or walk.307 years ago, two-thirds of American children A range of research continues to show a walked to school each day. Today, less than decline in physical activity as children enter one-in-five either walk or bike to school.306 adolescence and further ties “sedentary A 2007 study found that while approximately behaviors,” such as watching television and 35 percent of children lived within one mile playing video or computer games, with of their school, less than half routinely walked increased risk for obesity and increased or biked to school. Children living in south- snacking behavior. 308, 309, 310, 311, 312 ern U.S. states or rural areas were among the The National Coalition for Promoting Physical groups least likely to walk or bike to school. In Activity (NCPPA) has put together a series of addition, children of college-educated par- recommendations for ways to increase physical ents were less likely to walk or bike to school education and activity in schools. compared to children whose parents have 66 NATIONAL COALITION FOR PROMOTING PHYSICAL ACTIVITY RECOMMENDATIONS Actions That Could Increase Physical Education and Activity in Schools ■ Give equal standing to physical education as with other subjects in school, and foster opportunities for greater physical activity throughout the school day. ■ Provide adequate financial resources at both the state and national level to support quality physical education and health education including adequate classroom and activity facilities. ■ Allow adequate time in elementary and middle schools for daily recess that provides unstructured physical activity during the school day. ■ Schools should regularly evaluate the physical fitness of their students and their physical activity programs, and make the findings public, so that parents can be assured that their children are participating in and benefiting from physical education, sports, and recreational opportunities offered by the school. ■ Federal agencies and national organizations should disseminate tools to help schools improve their physical education programs and foster opportunities for greater physical activity. Items That Could Increase Physical Activity in the Before and After School Settings ■ Modifications to the built environment surrounding schools to increase safety for physical activity ■ Low- or no-cost intramural and physical activity programs for all students ■ Crossing guards at major intersections ■ Safe, accessible bike racks and storage areas ■ Open gyms and all purpose rooms for play and organized sports with supervision ■ Readily available basic medical and emergency care ■ Service learning that involves physical activity, such as cleaning and painting EXAMPLES OF SUCCESSES IN SCHOOL-BASED APPROACHES ■ The Child and Adolescent Trial for Cardiovascular Health (CATCH) elementary-school program encompassing 3,714 students in 96 schools in 4 states focused on providing education for stu- dents, modifications for improvements in school lunches and physical education, and increased education for staff and teachers.313, 314 The program showed positive results with students con- suming healthier diets and engaging in more physical activity. The findings suggest that a pro- gram that encompasses a school-based approach can yield improvements. Activity levels for students at the older age ranges of the study began to dissipate toward the end of the study, demonstrating an increased need to continue with middle and high school interventions. ■ A 2001 research study found that supervision and access to recreational facilities increased activity levels of students. 315 Also, studies have shown that programs aimed at improving student participation in physical activity generally have positive results.316 For example, one study provided 24 high schools with a physical activity intervention that was delivered through coordinated school health program components (the Lifestyle Education and Activity Program (LEAP)), which resulted in increased activity among girls.317 67 FEDERAL INITIATIVES TO SUPPORT SCHOOL-BASED APPROACHES CDC has supported school-based obesity initiatives by: ■ Establishing a Coordinated School Health Program as a model for how to integrate a range of school and community efforts. These include: physical education; health education; health services; nutrition services; counseling, psychology, and social services; encouraging healthier school environments; providing health promotion for school staff; and family and community involvement; ■ Creating a School Health Index self-assessment and planning guide for schools, which is available online at http://apps.nccd.cdc.gov/shi/NewUser.aspx; ■ Developing a Physical Education Curriculum Analysis Tool in partnership with physical education experts across the country, which is available online at http://www.cdc.gov/HealthyYouth/PECAT/index.htm; ■ Administering the School Health Policies and Programs Study and School Health Profiles survey related to children’s health in schools; and ■ Division of Adolescent and School Health (DASH) cooperative agreement funds are awarded by the U.S. Department of Education to state departments of education in 23 states in FY 2006. The state education departments work with state health departments to strengthen school-based policies and programs that address obesity and chronic disease. ■ Steps to a Healthier US includes a school health goal in every Steps community. LEARNING IN MOTION: STEPS TO A HEALTHIER U.S. INITIATIVE In Rockland County New York, 140 teachers have participated in the Steps to a HealthierNY’s Learning in Motion: Physical Activity, the Brain and Achievement course reaching more than 19,800 students in 41 school buildings. This course is a 3-credit graduate course for classroom teachers that encompasses the concepts of brain develop- ment, the relationship between movement and learning, and strategies for using move- ment to teach core academic concepts. Classroom teachers learn: why children need to move (the relationship between brain functioning and movement); and how to incorpo- rate movement and multi-sensory experiences into differentiated learning. They learn how using movement to teach academic subjects enhances their overall understanding of subject matter content.. In addition, they understand how including movement into classroom learning experiences improves brain function, academic success, and healthy lifestyles. As a result, students experience increases in fitness, body awareness, and attention to focus and decreases in stress. A one-credit in-service course is also offered and covers the same material in less depth. Based on a survey of teachers who attended the program, 95 percent use physical activity in their classroom at least several times a week and 85 percent use it daily or several times per day. 68 COMMUNITY PLAY INDEX In February 2007, Stanford University’s School of Medicine released Building “Generation Play”: Addressing the Crisis of Inactivity Among America’s Children, which examines the current childhood obesity epidemic and factors contributing to physical inactivity in youth. The report provides recommendations for how to increase physical activity in children at various intervention points, including at the community level. The report recommended that communities design evaluation tools, such as a “Community Play Index,” to assess the availability of opportunities for physical activity in the area and, if needed, to improve upon these opportunities.318 That same month, Senator T Harkin (D-IA) introduced legislation, known as the Promoting Lifelong om Active Youth (PLAY) Every Day Act, which calls for the development of a Community Play Index to measure the policy, program, and environmental barriers in communities to youth participating in phys- ical activity.319 The legislation also calls for awarding grants to state health departments to: ■ Train communities on how to use the Community Play Index. ■ Fund community coalitions to design and implement model communities of play by (1) increasing the amount of space available for physical activity; (2) expanding opportunities avail- able for children and families to be physically active and to participate in physical education programs; and (3) increasing community members’ awareness and knowledge about the importance of youth achieving 60 minutes of physical activity every day.320 3. Community-Based Approaches From coast-to-coast, communities are under- places, school settings, health care facilities, taking a wide range of efforts in an attempt organizations, or faith-based institutions.321 It to encourage increased physical activity. stresses targeting efforts based on different groups’ levels of receptivity to change, life In 1999, CDC issued Promoting Physical Activity: stages, and settings. It also emphasizes bal- A Guide for Community Action to help commu- ancing expectations for individual change nity leaders, business leaders, and public within the context of the communities where health officials develop strategies to motivate people live. For instance, factors like access to increased physical activity. The guide is recreational facilities influence decisions peo- intended to help communities promote phys- ple make about physical activity. ical activity in settings ranging from work- 69 EXAMPLES OF STATE AND COMMUNITY INITIATIVES INShape Indiana: Healthier Workers Mean a Healthier Economy In July 2005, Governor Mitch Daniels launched INShape Indiana to help “Hoosiers to make healthy choices by linking them to valuable resources and offering a fun challenge to improve their health and well-being. INShape Indiana is not another program; it is an initiative to coor- dinate the many efforts taking place across the state to combat obesity and smoking.”322 Governor Daniels argued that for his state to be economically competitive, his constituents needed to be healthier. He did not want to lose business development to other states with healthier workforces and urged “Millions of Hoosiers” to “help our economic comeback gain momentum by participating in INShape Indiana.”323 INShape Indiana was launched at a statewide health summit that brought together leaders from health, business, and education from all around the state. Following that event, 47 county coalitions formed in collaboration with the Purdue Cooperative Extension Service to address obesity preven- tion at the local level. The summit has become an annual event. The upcoming October 2007 sum- mit will focus on worksite wellness, which is a term that applies to facilities as well as employee phys- ical and mental health issues that lead to business costs such as medical and disability claims. The program is anchored by a website that provides an information clearinghouse for pro- grams and activities around the state pertaining to nutrition, exercise, and smoking cessation. It also links to dozens of health-related sites. In its first year, the Web site received 6.1 million hits from individuals seeking information on living healthier. There were 14,000 participants in INShape Indiana in its first year, and with the launch of the 10 in 10 campaign this year, a statewide challenge to lose 10 pounds in 10 weeks, the number of participants rose to 42,000 participants from all of Indiana’s 92 counties. Over the past 2 years, INShape Indiana has also partnered with the Department of Natural Resources to hold walks in state parks and has created an INSight Youth Corps, training high school students in peer education on healthy lifestyle choices. North Carolina Wellness Initiative The Department of Health and Human Services (DHHS) Wellness Initiative was launched in 2004 as a 3-year partnership with the State Health Plan’s North Carolina (NC) HealthSmart Initiative and the North Carolina DHHS.324 The program focuses on the department’s 18,000 employees. A full-time Wellness Director position was created to work with the department’s 21 agencies and 17 facilities to establish wellness committees and wellness programs focused on policy and environmental change that will address the major behavior risk factors for chronic disease. Wellness representatives from each agency and facility serve as members of a new department level Wellness Council to advise the Department on the needed changes to improve workplace support for employees to become more active, eat smart, avoid tobacco, and manage stress. After one year, committees were established in all 38 agencies and reported significant improvements in workplace support for physical activity and healthy eating, including: ■ Indoor fitness areas increased from 14 to 22 worksites; ■ The availability of healthy vending/meal options increased from 10 to 24 sites; ■ 17 agencies developed healthy food policies for agency events; and ■ 27 agencies created policies supporting employees being more physically active in the workplace. Of 4,788 employees responding to a survey about the initative, 61 percent participated in sponsored worksite wellness activities; 45 percent reported walking and/or exercising more often in the past year; 46 percent reported choosing healthier snacks/meals more often; 43 percent said they were eating more fruits and vegetables and 33% were eating fewer high fat foods; and 23 percent reported moving closer to a healthy weight. The Secretary made several policy changes based on recommendations from the Wellness Council to increase support for employee wellness, including authorizing employee access to existing patient fitness facilities, creation of a central employee fitness center with gym, a require- ment of at least five percent healthy selections in vending contracts, and top management sup- porting flex-time work schedules to allow employees to participate in wellness activities. 70 Healthy Communities Moses Lake in Washington State Through funding from CDC’s Division of Nutrition and Physical Activity, the Moses Lake com- munity of Washington state initiated a Healthy Communities Moses Lake project, which “encourages good nutrition and physical activity through environmental and policy change.” The project aims to implement various smart growth policies, such as widening sidewalks and creating additional paths for pedestrians and cyclists, to increase physical activity among com- munity members and tourists. The project also hopes to improve the nutrition of local resi- dents through a community garden project.325 As of 2006: ■ The City of Moses Lake, which attracts tourists for its significant sand dunes, initiated a plan to replace a railroad track that runs through the downtown area with a path for biking and walking. ■ Grant County adopted a plan to create walking and biking trails alongside irrigation canals. ■ “New zoning ordinances in both the city and county require wider sidewalks that will increase accessibility for pedestrians and cyclists.”326 ■ The community garden project has established links with “local school groups and chefs to make the garden both a food source and educational tool for the community.”327 Shape Up Somerville in Massachusetts Over the past five years, Somerville, a town of 78,000 located outside of Boston, has made changes throughout its community in an attempt to curtail rising childhood obesity rates. Before the effort began, 44 percent of the town’s first-, second-, and third-graders were con- sidered overweight or at risk of becoming overweight. The program, called Shape Up Somerville, is believed to be the first controlled experiment evaluating the effectiveness of a community-based environmental change intervention in preventing weight gain in children.328 Designed by researchers at the Tufts Friedman School of Nutrition, Shape Up Somerville led to the following environmental changes in the community: ■ Various Somerville restaurants now serve low-fat milk and smaller portion sizes. Those that do are designated as Shape Up partners. ■ The school district has nearly doubled the amount of fresh fruit at lunch and now uses whole- grain bread products to boost students’ fiber intake. Schools also obtained food processors and fruit juicers to make serving fresh fruits and vegetables easier for the kitchen staff. ■ Crosswalks around town have been repainted to encourage more people to walk to work and school. ■ Somerville targeted crossing guard placement on areas where children are most likely to walk to school and distributed maps of the newly staffed routes to parents. This change led to a 5 percent increase in the number of children who walk to school. ■ With help from a grant from the Robert Wood Johnson Foundation, the town expanded a local bike path that will eventually go all the way to Boston. ■ The city council started to offer reimbursements for gym memberships for city employees and put in dozens of new bike racks for schools and streets. ■ Tufts researchers held parent meetings in various languages to explain the importance of the program. They also held health fairs, gave away pedometers, and organized a community fun run.329 In a 2007 study published in Obesity, Tufts researchers evaluated the first year of the program and found that children in Somerville gained less weight than children in surrounding communities.330 71 YMCA ACTIVATE AMERICA The mission of YMCA Activate America is to help kids, adults, families, and communities lead healthier lifestyles. More than 80 percent of the 2,617 YMCAs across the country are engaged in YMCA of the USA’s Activate America initiative. More than 100 YMCAs are making organizational changes to better serve those individuals wanting to lead healthier lifestyles. These local YMCAs are also transforming their child care sites into environments that encourage healthy eating and physi- cal activity.331 As part of the YMCA Activate America initiative, each spring more than 1,400 local YMCAs host an activity-filled YMCA Healthy Kids® Day, which uses activities to encourage “children and families to adopt behaviors that support a healthy lifestyle.”332 Pioneering Healthier Communities In July 2004, with funding from CDC, YMCA of the USA launched the Pioneering Healthier Communities (PHC) project as part of its overall Activate America initiative.333 The mission of PHC is “to (1) raise the visibility of lifestyle health issues in the national policy debate, and (2) encourage and support local communities in developing more effective strategies to promote healthy lifestyles.”334 As of 2006, 46 communities across the country have become active PHC sites.335 Examples of what PHC sites have done to promote healthier lifestyles among their residents include: ■ Offering fresh fruits and vegetables and encouraging physical activity during after school programs. ■ Influencing policy leaders to “put physical education back in schools and include physical activity in after school programs.” ■ Building new or enhancing old walking and biking trails and sidewalks to encourage physical activity among residents. ■ Increasing residents’ access to fresh fruits and vegetables “through community-gardens, farmers markets, and other activities.”336 A Community Health Living Index YMCA of the USA plans to develop and test a community assessment tool that will provide communities with an instrument to measure qualitative information about physical activity and healthy eating resources; policies and programs and quantitative data about physical activity; and health eating assets and needs. The Community Health Living Index (CHLI) will be used by YMCAs in communities across the country next year as part of YMCA Activate America, and will be made available to other community-based organizations to measure the availability of and access to healthy eating and physical opportunities in their communities. 72 EXAMPLES OF YMCA PIONEERING HEALTHIER COMMUNITIES Des Moines, Iowa It is estimated that approximately 40 percent of Des Moines middle-school children are overweight. In response, Des Moines became a PHC site (called Activate Des Moines) and developed Trim Kids, a 12-week program that teaches parents and overweight chil- dren to take the steps necessary for long-term healthy living by providing menu ideas, easy exercises and tips for parents so they can encourage their kids. As of 2006, more than 600 individuals have participated in Trim Kids and the program is expanding to 12 new communities. In addition, leaders of Activate Des Moines helped convince the Des Moines School Board to require healthier options for snacks served in schools and in school vending machines.337 Milwaukee, Wisconsin Milwaukee’s PHC project focuses on reducing health issues related to overweight youth and their families, particularly those from low-income areas. To achieve this goal, the Milwaukee team has developed healthy-living programs for children and teens. ■ Milwaukee’s elementary school program, a 12-week session for 4th and 5th graders, provides information about proper fruit and vegetable consumption and encourages students to increase their level of physical activity. During the program, participating students and their families receive a free YMCA family membership.338 ■ Milwaukee residents aim to build a healthier, safer, walk-able and bike-able community. The Milwaukee PHC team and other groups conducted a walk-able neighborhood study, including determining priority areas for curb-outs, round-abouts, bike lanes, and countdown crosswalk meters. Over the long-term, the community plans to add trees and other attractions and create a map outlining key sights and historical landmarks. The Milwaukee PHC team is working in collaboration with various community part- ners, including the Milwaukee County Transit System, the Milwaukee Department of Public Works, and the Milwaukee Police Department, to implement the environmental improvement project.339 NATIONAL RECREATION AND PARK ASSOCIATION With over 6,000 public parks and recreation agencies that serve over 200 million people each year, the National Recreation and Park Association (NRPA) launched a multi-year community- centric strategic effort in 2001 to address the nationwide issues of physical inactivity and poor diet that have contributed to the expanding obesity epidemic. Through a partnership with the National Heart, Lung and Blood Institute of the National Institutes of Health, a three year field study, Hearts ‘N Parks, was led by park and recreation professionals in 56 communities across 10 states with high rates of cardiovascular disease. The field study resulted in the launch of a NRPA Step Up to Health Initiative. NRPA has conducted 32 Step Up to Health Summits since February 2005. More than 2,000 individuals have been trained in the Community Mobilization Model and over 700 communities have joined the Step Up to Health program.340 73 4. Working with Health Care Providers Studies have shown that educating doctors Two surveys including obese adults who about providing better counseling to annually visited their physicians at least patients about physical activity and nutrition once a year found that fewer than half of the has been an important factor in influencing obese patients had been advised to lose patient behavior change.341 weight or exercise.342 The majority of Americans come in contact with Of those who were overweight, only 35 per- a health care provider at least once a year due to cent had been counseled on exercise. Of sickness or for a health check-up. Each patient individuals who were sedentary, only 22 per- visit provides an opportunity for health care cent had been counseled by their physician providers to discuss the health benefits of prop- about exercise.343 er nutrition and physical activity with patients as A number of barriers have been identified well as to screen for individuals who may be at- that impede health care providers from risk for weight-related health problems. providing effective obesity and physical This section identifies a series of barriers that inactivity screening and treatment to their impede health care providers from routinely patients. providing obesity and physical inactivity screening and treatment to patients. Barrier #1: Lack of Physician Awareness and Training properly addressing family conflicts (30.0 percent) among Physicians often do not receive proper training about effective obese child patients and their guardians.346 screening and treatment of obese and sedentary individuals, In a statewide survey of 240 providers in California, more according to a number of studies. Therefore, these physicians than 90 percent responded that they felt they needed more feel unprepared to provide patients with diet and physical training in strategies and skills for communicating with parents activity counseling and behavioral therapy and other obesity- about their child’s weight problems. In response to these related services. In a survey conducted by the American results, Children’s Hospital & Research Center Oakland Medical Association, 56 percent of graduating medical students (CHRCO) launched a series of workshops in 2006 to teach indicated that “nutrition-related experiences during their train- physicians how to talk to parents about their child’s obesity- ing were inadequate” and only 50 percent felt that “they were related health problems.347 Kaiser Permanente has also start- well prepared to assess patients’ status for obesity.”344 ed offering their providers with similar training about how to In an attempt to enhance providers’ knowledge of proper counsel families regarding prevention and management of obesity-related treatment services, some insurers are offering conditions in overweight children.348 educational opportunities and other tools to providers. For example in 2006, Blue Cross of California (BCC) launched a Barrier #3: Lack of Reimbursement for Obesity Services statewide BMI training and promotion program for clinical The 2002 Pediatrics survey also found that 46 percent of pedi- staff (registered nurses, licensed vocational nurses, and med- atricians said reimbursement is seen as a barrier in the treat- ical assistants) throughout California in an attempt to combat ment of overweight children and adolescents. Fifty-eight per- the childhood obesity epidemic. The program, called “Taking cent indicated that lack of clinician time was a barrier.349 Measures for Their Future,” will reach more than 9,000 pedi- Physicians are likely to focus limited time they have on the atric and family practices.345 health issues that instigate a patient’s visit to the doctor, and not on other apparent issues, such as excessive weight. Barrier #2: Lack of Training for Communicating Delicately and Effectively with Patients about Weight Problems Changes to reimbursement policies could provide a financial incentive for physicians to become more engaged in screening In a survey of pediatricians published in 2002 in Pediatrics, for and treating obesity-related concerns. If policies were to many providers said they felt they had low levels of proficiency change encouraging obesity screening, physicians would be dealing with behavior management strategies (38.9 percent), more likely to address issues of patients who present with providing guidance in parenting techniques (25.0 percent), and obesity and physical inactivity issues. 74 REACHING CHILDREN AND YOUTH THROUGH HEALTH CARE PROVIDERS Children and youth routinely have well-care examinations by doctors, providing a strong opportunity for evaluation and counseling related to activity and nutrition. Research featured in the 2006 Future of Children journal regarding childhood obesity suggested that “given the magnitude of the childhood obesity problem, however, pediatricians and other health care providers are going to have to step up and take a major role in the care and health of the obese child. Successfully treating obesity will require a major shift in pediatric care.”350 The American Academy of Pediatrics recommends that pediatricians ask parents a variety of questions to gauge children’s physical activity, such as “the number of times per week their child plays outside for at least 30 minutes” and “the number of hours per day their child spends in front of a television, video game, or computer screen.”351 Further, they suggest the use of pedometers because of the ease with which the device can evaluate the number of steps and because of their “gadget appeal among youngsters.”352 Many children and youth receive health care coverage based on their parents work insurance plans. Exploring changes to these policies to encourage an emphasis on well-care including physical activity and nutrition counseling could have a significant impact on preventing and controlling childhood obesity. EXAMPLE OF INSURERS DEVELOPING CHILDHOOD-FOCUSED PROGRAM Blue Cross of California has “developed and distributed a Childhood Obesity Physician Toolkit to the 12,000 pediatric and family practice physicians in its network, which pro- vides information to help physicians engage families in dialogue about their child’s weight, nutrition and physical activity, and offers an online Childhood Obesity Continuing Medical Education (CME) Course developed in partnership with the CMA foundation and designed to screen, identify, and manage at risk and overweight pediatric patients.”353 The Section 2: State Responsibilities and Policies provides some examples of states offering childhood Medicaid benefits. DEVELOPING BEST PRACTICES FOR HOSPITALS IN THE FIGHT AGAINST CHILDHOOD OBESITY The Youth Obesity Learning Collaborative, created in early 2006 by the Association for Community Health Improvement of the Health Research and Educational Trust, involves 15 rural, urban, and suburban hospitals from around the country that are working to implement successful childhood obesity prevention and reduction programs in their communities. The ultimate goals of the Learning Collaborative are to “enhance the effectiveness of participants’ initiatives and to develop guidance for other hospital-based partnerships working to reduce youth obesity and its negative impacts on health.”354 Through the collaborative, member hospitals participate in face-to-face and virtual meetings to exchange intervention strategies, outcomes, and measurement tools and data.355 They are also involved in developing case studies and a web-based guidebook to help other hospitals implement successful childhood obesity programs in their communities. The guidebook will be available in late summer of 2007. 75 5. Workplace Approaches The workplace is considered an important Twenty-five percent of Fortune 1000 compa- setting for reaching adults since people are nies are expected to have on-site medical influenced by their employers’ practices clinics by the end of 2007, according to and policies. Employers can create an envi- Watson Wyatt Worldwide Inc. It is estimated ronment that encourages workers to engage 15 percent had these types of clinics avail- in increased physical activity, by supporting able in 2006.358 gym memberships or offering workout facil- Return on investment (ROI) for large cor- ities on-site and supporting breaks through- porate health management programs has out the day where people are encouraged to been shown to range from $1.49 to $4.91 be active (such as taking a walk). per dollar spent, with a median of $3.14.359 Wellness programs typically also concen- Some studies suggest that significant finan- trate on improving eating habits in addition cial benefits often are realized only over to encouraging increased physical activity. time periods, particularly in companies where employee turnover is low. 360 According to the Society for Human Concerns about costs have deterred many Resources Management, 43 percent of smaller and medium businesses from employers “who offered health insurance investing in wellness programs. Experts also offered some type of incentive to suggest that insurers could step in to encourage healthy behavior” in 2006.356 In address the needs of small and medium addition, the number of employers offering sized employers to be able to affordably weight-loss programs specifically increased provide wellness programs. from 17 percent in 2001 to 29 percent in 2006, representing a 71 percent increase.357 HEALTHY WORKFORCE ACT U.S. Senators Tom Harkin (D-IA) and Gordon Smith (R-OR) have introduced the Healthy Workforce Act of 2007 to assist businesses in providing a range of opportunities to help employees lead healthier lives, including incentives to offer onsite health promotion programs. The bill would provide tax credits to businesses that offer comprehensive wellness programs to their employees. Businesses could receive the tax credit for 10 years for establishing new qualified wellness programs. Employee wellness programs eligible for the tax credit may include: ■ Raising health awareness through health education and health risk assessments. ■ Behavioral change programs that encourage employees to lead a healthy lifestyle through counseling, seminars or on-line programs. Programs could include classes on nutrition, stress management, or smoking cessation. ■ A meaningful program participation incentive, such as individual reductions in health insur- ance premiums. 76 EXAMPLES OF BUSINESS WELLNESS EFFORTS Lighten Up Dow Chemical ■ Holds health fairs; With more than 60 percent of its U.S. workforce either over- ■ Pays as much as $300 in incentives for healthy activities weight or obese, the Dow Chemical Company has begun to such as losing weight or quitting smoking; and encourage weight management and physical activity for ■ Has negotiated affordable YMCA membership plans for its approximately 10,000 employees at 12 work sites around the employees.364 country. Plans include: Nordam estimates that for every $1 that the company invests in ■ Work with food service and vending companies to reduce its wellness program, it gets a return of between $2.50 and $6.365 the amount of high-fat and high-sugar items offered; ■ Put up signs to encourage people to take the stairs instead Minnesota Fittest State Initiative of the elevator; The Minnesota Fittest State Initiative was launched in 2007 by state ■ Offer weight management tracking programs; and business and policy leaders, targeting 2 major health risk factors: ■ Implement walking paths and routes around the buildings.361 physical inactivity and unhealthy eating. Fittest State is being led by The company estimates that if successful, the program could Blue Cross and Blue Shield of Minnesota (BCBSMN), with support reduce corporate health care costs by more than double the from area businesses, including General Mills and Medtronic, and costs of their investment in the wellness program.362 local chapters of the American Heart Association and the American Cancer Society. Nordam Group ■ The initial focus of Fittest State will be on implementing The Nordam Group, an aerospace manufacturer based in physical activity and nutrition interventions in the workplace. Tulsa, Oklahoma, recently implemented a wellness program ■ Long-term, the program aims to move beyond employer for its employees and experienced a savings of $454,000 in programs to reach families, children and communities. medical costs during the first year of the program’s BCBSMN will make funding available for employers interest- operation.363 The company’s wellness program encourages ed in implementing worksite wellness programs and for com- exercise, healthy eating, and smoking cessation among its munities to make walking and biking routes safer. In addition, employees. The company also: program partners can host forums to allow business leaders ■ Sponsors employee teams for local runs and walks; to share best practices and informational resources.366 EXAMPLE OF ESTABLISHING WELLNESS PROGRAMS FOR SMALL AND MEDIUM SIZED EMPLOYERS In March 2007, Blue Cross and Blue Shield of Minnesota their root causes -- tobacco use, lack of physical activity and (BCBSMN), the state’s largest private insurer, created a unhealthy eating.” The only requirement from BCBSMN is “Workplaces on the Move” initiative that “will select up to that the programs promote better health by encouraging 20 [small- to mid-sized] employers [in 2007] to receive 3- employees to increase their level of physical activity.368 year contracts that range in value from $25,000 to $100,000 The Workplaces on the Move initiative provides examples for depending on the size of the company.”367 other small- to medium-sized organizations on ways to imple- Through Workplaces on the Move, BCBSMN’s goal is to ment wellness programs for their employees. “tackle preventable heart disease and cancer by addressing NEW NON-DISCRIMINATION REGULATIONS FOR EMPLOYER WELLNESS PROGRAMS New non-discrimination rules went into effect in July 2007 capped at 20 percent of a single employee’s insurance premi- to help ensure that employer wellness policies are not um.370 In addition, employers will be required to provide “rea- overly punitive to those who cannot alter their lifestyles. sonable alternatives” in their wellness policies for people with The rules, issued in December 2006 by HHS and the physical or medical conditions. For example, since nicotine Department of Labor (DOL), are part of the Health addiction is considered a medical condition, employers general- Insurance Portability and Accountability Act (HIPPA).369 ly will be required to make allowances in health plans and well- ness programs for workers who have been unable to quit.371 The maximum discount an employer or insurer can provide to employees for taking part in a wellness program will be 77 6. IMPROVING THE BUILT ENVIRONMENT A significant advancement in obesity research The built environment and community design, is a growing recognition in the field of the including available retail and restaurants and built environment, which is often defined as transportation to food retail locations, impact the man-made aspects of communities. physical activity and eating patterns.372 SOME KEY BUILT ENVIRONMENT FACTORS ■ Sidewalks ■ Safety of communities ■ Bike paths ■ Sprawl ■ Street layout ■ Neighborhood availability of stores and restaurants offering healthy or less healthy ■ Recreational spaces, such as parks and selections of food choices community centers ■ Proximity of stores and offices within walking distance of homes A number of studies have examined the traffic, no safe route (17 percent), fear of influence of the built environment on phys- abduction (16 percent), crime in the neigh- ical activity. borhood (6 percent), lack of convenience (15 percent), and finally, children not want- ■ Researchers have found that people walk ing to walk (6 percent).”378 and bike less in communities that are “less dense” or where shopping and places of ■ Youth from low-income families often work are spread out in distance.373 have the least access to safe venues for physical activity. The GAO found that ■ One study found that sprawl was associated “areas of low socioeconomic status and with people walking less, higher rates of high minority populations had fewer ven- obesity, and higher levels of hypertension.374 ues for physical activity” and “adolescents ■ A research group concluded higher physi- in unsafe neighborhoods engage in less cal activity and lower obesity levels could be physical activity” than their peers.379 seen in more “walkable” communities.”375 ■ A 2005 analysis of the National Household ■ A study that examined 13 countries with a Transportation Survey showed that resi- wide variety of types of cities found obesity dents in large urban areas with rail transit declines in communities with more “mixed systems are much more likely to walk for land use” (closer proximity of home to utilitarian purposes.380 Those in large urban stores and work places), and rises with time areas without a rail transit system were still spent in a car daily, even when controlling more likely to walk, but to a lesser extent.381 for factors such as age, income, education, ■ Additional studies have found that a lack and gender/ethnicity.376 of “green spaces” and other recreational ■ Most school-aged children are either driven areas may contribute to higher obesity by a parent (53 percent) or a school bus (38 rates. For instance, fewer parks and swim- percent). Less than 2 in 10 (17 percent) ming pools are typically available in com- walk.377 The study concluded that “the main munities with high levels of poverty and reason their children do not walk or bike is with greater numbers of African because the school is too far away (66 per- Americans and Latinos, who have higher cent). Other concerns include too much rates of overweight and obesity.382 78 PREVENTION INSTITUTE’S ENACT: ENVIRONMENTAL NUTRITION AND ACTIVITY COMMUNITY TOOL The Prevention Institute has produced an Environmental Nutrition and Activity Community Tool (ENACT) to provide “a hands-on assessment and planning resource for organizations, coalitions and communities interested in improving their nutrition and physical activity environments.”383 It provides a “concrete menu of strategies designed” to help communities assess and improve the local environment in which they live.384 ENACT focuses on seven different settings or sectors: childcare, school, after-school, neighborhood, workplace, healthcare, and government. RECOMMENDATIONS FOR IMPROVING COMMUNITY DESIGN TO ENCOURAGE INCREASED PHYSICAL ACTIVITY AND MORE NUTRITIOUS EATING HABITS From TFAH’s 2005 F as in Fat report developed in consultation with Smart Growth America: ■ Encourage “Mixed Use” Areas. Communities and states should examine and update zoning and land use laws to allow for more “mixed use” commercial and residential com- munities, so people can have more opportunities to walk or bike to retail centers and to work. ■ Examine Health Impact of New Building. Communities should require “Health Impact Assessments” for proposed land use and building projects, which will help communities and policymakers understand how community health might be affected if new building restricts access to recreational space and to food shopping. These can be based on the “Environmental Impact Assessment” model. ■ Building Design Codes. Encourage new building design that encourages use of staircases rather than elevators or escalators and offers other spaces that facilitate activity in com- mercial and public buildings. ■ Build More Sidewalks. Communities should place greater emphasis on building side- walks, particularly in new developments and around highways, to make it possible for peo- ple to walk safely. ■ Encourage Transportation Fund Use for Mass Transit and Alternatives to Highways. Communities should insist that states and counties require alternative propos- als be examined when new highway initiatives are proposed. New development should also be required to include pedestrian-friendly components, such as sidewalks, which encourage interconnectivity of communities and opportunities for activity. State and feder- al transportation dollars should be considered for mass transit, sidewalk, and mixed use opportunities rather than be focused on highway construction. ■ Modernize New School-Site Construction Requirements. States and localities should review and update old acreage requirements for new school construction that required large spaces for construction. Outdates requirements have resulted in schools being built in remote locations that students can often only access by bus rather than by walking or biking. Flexible standards for school site construction would allow communities to build schools closer to existing homes and commercial regions instead of in remote areas. ■ Providing Improved Healthy Food Access in Low-Income Areas. Healthy food access is a demonstrated problem in many low-income communities. Communities should encourage the development of and provide public space for locally-operated produce mar- kets and farmers markets. Also, through the use of incentives, communities should encourage supermarkets and food shopping vendors to locate in lower-income neighbor- hoods and offer healthier food alternatives. 79 Survey of Chronic Disease Directors and Directors of Health Promotion 5 SECTION and Education I n order to understand which obesity prevention and reduction strategies experts believe are most effective and should be prioritized, TFAH con- ducted a survey of state Chronic Disease Directors (CDDs) and state Directors of Health Promotion and Education (DHPEs). CDDs and DHPEs are state government employees who serve on the front lines of public health in each state by developing and implementing policies and programs to pre- vent chronic disease and promote better health. In July 2007, the National Association of Survey Monkey (www.surveymonkey.com) Chronic Disease Directors (NACCD) and the and was available for a period of over 2 weeks. DHPE association distributed a survey by Thirty-three out of 50 CDDs and 21 out of 50 email to their members. The survey was DHPEs responded to the survey (See administered through the Internet service Appendix B for a list of survey participants). A. BARRIERS TO SOLVING THE PROBLEM OF OBESITY IN ADULTS Overall, the CDDs and DHPEs expressed More than 80 percent of CDDs and DHPEs concern about a number of issues that serve responded that all 9 of the potential barriers as barriers to preventing and controlling listed in the survey were either a major or adult obesity. The barriers respondents felt minor barrier to addressing the challenge were most significant included: of obesity. ■ Lack of funding; When asked specifically what action the fed- eral government could take to combat the ■ Lack of political leadership on the adult adult obesity problem, many of the CDDs obesity issue; and and DHPEs identified increased federal ■ Unhealthy settings in which adults live funding for obesity-related research and day-to-day (e.g., the workplace or sur- interventions for adults. rounding built environment not being conducive to physical activity, limited access to nutritious foods, etc.). 81 Barriers to Solving Adult Percentage Percentage Obesity Problem Indicating Barrier Indicating Barrier as MAJOR as MAJOR or MINOR Lack of population health funding for health 90.6% 100% promotion and disease prevention Environmental factors (e.g., limited sidewalks and green space, unsafe neighborhoods, 86.8% 100% urban sprawl and reliance on cars, etc.) Workplace settings not conducive to healthy 79.2% 100% eating and physical activity Lack of leadership on the issue (e.g., obesity is not a political priority, government funds 76.9% 100% not being allocated to the issue, etc.) Limited access to nutritious foods, such as fruits and vegetables, due to high prices or 70.4% 94.5% limited availability in certain areas (e.g., inner-city neighborhoods) Lack of reimbursement for obesity treatment services (e.g., nutritional therapy, behavioral 58.5% 92.5% counseling, etc.) Under-diagnosis of obesity and overweight 40.7% 83.3% within the primary care setting Inconclusive research regarding appropriate 35.2% 81.5% interventions Unclear and inconsistent messages regarding 31.5% 83.4% nutrition and physical activity B. BARRIERS TO SOLVING THE OBESITY PROBLEM IN CHILDREN AND ADOLESCENTS The CDDs and DHPEs reported the top ernment could take to help combat childhood major barriers for combating obesity in chil- obesity, many of the respondents identified dren and adolescents included: increased federal funding for obesity-related ■ Unhealthy settings in which children and research and interventions for youth. adolescents live day-to-day; For adults, only 31.5 percent of CDDs and ■ Lack of funding; and DHPEs identified “unclear and inconsistent ■ Lack of political leadership on the issue. messages regarding nutrition and physical activity” as a major barrier to combating the For children and adolescents, unhealthy living adult obesity problem, however, the majority settings encompass the home (i.e. physical (52.8 percent) of respondents listed these activity and eating patterns of parents), school messages as a major barrier in the fight against (e.g., cuts in physical education, lack of childhood and adolescent obesity. One reason healthy foods served in schools, etc.), and the for this may be due to the fact that the major- built environment (e.g., limited sidewalks). ity of physical activity level recommendations Also, the CDDs and DHPEs felt that overall for children and adolescents have been based limited funding for public health programs is a on studies involving adults and not youth. problem, but that it is compounded in dealing The majority, more than 85 percent, of CDDs with childhood obesity since limited financial and DHPEs felt that all of the issues included resources at the school level also cuts into phys- in the survey were either major or minor bar- ical and health education programs. When riers to addressing childhood obesity. asked specifically what action the federal gov- 82 Barriers to Solving Childhood and Percentage Percentage Adolescent Obesity Indicating Barrier Indicating Barrier as MAJOR as MAJOR or MINOR Physical activity and eating patterns of parents 96.3% 100% Cuts in physical education, recess and health 92.5% 100% education at schools Lack of population health funding for health 84.9% 100% promotion and disease prevention Environmental factors (e.g., limited sidewalks 83.0% 100% and green space, unsafe neighborhoods, etc.) Lack of healthy foods in schools and school funding methods that require soda or other 74.1% 100% vending contracts to make ends meet Lack of leadership on the issue (e.g., obesity is not a political priority, government funds 67.9% 98.1% not being allocated to the issue, etc.) Unclear and inconsistent messages regarding nutrition and physical activity requirements 52.8% 88.6% for children and adolescents Under-diagnosis of obesity and overweight 52.8% 90.5% within the primary care setting Lack of reimbursement for obesity treatment services (e.g., nutritional therapy, behavioral 51.9% 94.5% counseling, etc.) Inconclusive research regarding appropriate 40.7% 85.1% interventions C. OBESITY AS A TOP STATE BUDGET PRIORITY The CDDs and DHPEs strongly felt that lack et priority, the CDDs and DHPEs listed vari- of funding was a serious barrier to combating ous other mandated public health programs the obesity problem in both adults and that take precedence over obesity given limit- youth. In addition, only half (50.94 percent) ed financial resources, including: infectious of respondents reported that obesity preven- diseases and emergency preparedness, “cate- tion and control was a top budget priority gorical” disease specific programs such as within their state department of health. In cancer prevention, and health services (e.g., states where it was not considered a top budg- Medicaid, WIC, senior services, etc.). D. PHYSICAL ACTIVITY OR WEIGHT LOSS: WHICH SHOULD BE THE FOCUS IN THE FIGHT AGAINST OBESITY? The majority of CDDs and DHPEs (64.2 per- physical activity, compared to only 5.7 per- cent) indicated that there needs to be a bal- cent who chose weight loss alone. These ance between focusing on physical activity results follow the idea highlighted earlier in and weight loss in the fight against obesity. the report that physical activity can lead to improved health outcomes in individuals Of the respondents who chose either weight independent of weight loss. loss or physical activity as the main focus in the fight against obesity, 28.3 percent chose 83 E. WAYS TO MEASURE SUCCESS The majority of CDDs and DHPEs rated take a long time to materialize or to show “prevalence of related chronic disease like progress. Many of the CDDs and DHPEs, diabetes” (58.5 percent) and “minutes and therefore, stressed the importance of also intensity of physical activity per week” (66.0 using short term-focused measures to evalu- percent) as good measures for evaluating the ate obesity interventions. Examples of short- effectiveness of obesity interventions. Forty term measures listed by respondents includ- five percent of respondents indicated that ed: environmental measures (e.g., access to BMI and nutritional intake measures (e.g., healthy foods and transportation opportuni- total caloric intake, dietary fiber intake, fat ties in communities), population physical intake, etc.) are good evaluation measures. activity and fitness levels, population televi- sion viewing time, physical education Many respondents indicated that changes in requirements in schools, and the number of BMI and obesity-related chronic disease worksite wellness initiatives. rates are long-term in scope and therefore F FOCUS OF FUTURE OBESITY PREVENTION RESEARCH AT NIH . When asked what their top research question ■ What are the top behavioral issues that would be if they could determine the contribute to obesity and what are the National Institutes of Health’s (NIH’s) most effective interventions that can assist research agenda for obesity, the majority of in changing those behaviors? CDDs and DHPEs listed questions focused ■ Are there evidence-based programs for dif- on finding the “best practices” for preventing ferent demographic populations (e.g., age, and treating obesity. These respondents sex, ethnicity, and geographical areas) to stressed the importance of using studies to combat obesity? uncover evidence-based/scientifically-proven obesity interventions and programs. ■ What treatment has shown to be the most suc- Examples of questions the CDDs and DHPEs cessful long term for weight loss and main- listed included: taining weight in overweight adolescents? ■ What mixtures of communication, coun- ■ What are the most effective programs for seling and policy/environmental change achieving weight loss and increasing phys- (e.g., improved sidewalks, increased ical activity among those at-risk for or with access to fruits and vegetables, etc.) yield obesity? the best results in modifying community ■ What obesity prevention and reduction obesity levels? interventions work in rural areas? 84 Public Opinion Survey A survey commissioned by the TFAH finds that 85 percent of adults think obesity has reached epidemic proportions in the United States, a figure that is consistent among gender, age, education, and racial breakdowns. 6 SECTION The survey was designed and conducted by one percent of Americans believe that Greenberg Quinlan Rosner Research, Inc. government should have some role in Interviewing was conducted by professional addressing the issue. interviewers. The survey reached 1,021 ■ Fifty-six percent of adults support the idea adults ages 18 and older. The survey was of funding government health budget pro- conducted July 12-16, 2007. The data were grams to strategically combat obesity. weighted by gender, age, race, and region, to ensure an accurate reflection of the pop- ■ Americans are very concerned about ulation. The sample size with these weights childhood obesity and see schools as a applied is 1,021 and is subject to a margin of starting place for tackling the obesity cri- error of +/- 3.1 percent at a 95 percent level sis. Less than one-third of adults think of confidence. that children participate in adequate amounts of physical activity during the The public also expresses a desire to see school day. Just 42 percent of Americans more action taken to resolve this epidemic. think that school lunches are nutritious Americans express a familiarity with and enough. The proposals which receive understanding of the need to maintain a the most support for how government healthy weight and participate in physical can help fight the obesity epidemic cen- activities. While they believe that people ter on schools and childhood obesity -- have a responsibility to tackle this issue at an increasing physical activity and starting individual level, a large majority also sees a before and after-school programs (71 need for government to play some role in percent rated as an 8 or higher on a 10 helping individuals accomplish those goals. point scale), and establishing higher This is particularly true with respect to nutritional standards for school lunches childhood obesity, where Americans show (66 percent rated as an 8 or higher on a strong concern about the lack of activity and 10 point scale). nutrition provided in schools. ■ Despite the rising prevalence of obesity, Key findings include that: most Americans have an awareness of the ■ Eighty-five percent of Americans believe steps that should be taken to avoid obesi- that obesity is an epidemic in this country. ty. On average, nearly two-thirds of Americans say that their doctor or health ■ Most people believe that government care provider has talked to them about should play some role in addressing the issues like weight management and exer- issue of obesity in the U.S. A majority of cise. Likewise, most can correctly identify adults (51 percent) say that the primary the government’s recommended level of responsibility for tackling the obesity epi- physical activity. demic should come from a combination of individuals and government. Eighty- 85 ■ The public responds favorably to propos- easier and less expensive to make the als that show government helping to make right choices. Majorities support propos- it easier for individuals to take the neces- als to expand educational programs sary steps to fight obesity and live health- about healthy living, provide low-cost ier lives. People have some awareness of access to exercise programs, and reduce what they should do to be healthy, but the marketing of unhealthy foods. they want government to help make it A. AMERICANS VIEW OBESITY AS AN EPIDEMIC The public is nearly united in the belief that This includes every demographic group, obesity has reached epidemic proportions including gender, age, income, racial, and in this country. Eighty-five percent of adults geographic breakdowns. say that the problem is at epidemic levels. Is obesity an epidemic in the United States? % Yes Total 85 White 85 African American 85 Hispanic 85 Men 81 Women 89 Ages 18-29 89 Ages 30-39 84 Ages 40-49 86 Ages 50-64 84 Ages 65+ 85 High school or less 81 Some college/post high school 89 College graduate 85 Less than $30,000/yr household 84 $30,000-$50,000/yr household 88 $50,000-$75,000/yr household 87 More than $75,000/yr household 86 Democrat 87 Independent 85 Republican 84 Northeast 86 Central 84 South 84 West 87 86 B. PEOPLE BELIEVE GOVERNMENT CAN HAVE AN EFFECTIVE ROLE IN FIGHTING THE OBESITY EPIDEMIC Americans believe that individuals play a big ■ African Americans and Hispanics are role in addressing chronic health issues like more likely to view a role for government. obesity, and that people can take action to A nearly universal 96 percent of African address these problems. Forty-five percent of Americans say government should have Americans think individuals and family are some role and 87 percent of Hispanics most responsible for addressing these health concur. Seventy-nine percent of white concerns, while just 2 percent believe that Americans see government as having a government holds the primary responsibility. role in combating obesity. However, people do believe government has ■ Women favor a government role more a role in addressing the obesity epidemic. than men. While more than three quarters Overall, a majority (51 percent) of adults of men (78 percent) want some govern- believes that individuals and government ment role, 85 percent of women support share the responsibility for combating obe- government playing a part in tackling the sity. Moreover, most who indicate that indi- obesity epidemic. viduals hold primary responsibility say that ■ The desire for a government role increas- government should have some role in tak- es as income level decreases. Americans ing on this issue. Together, this leads to a with the lowest levels of income are most staggering 81 percent of Americans who eager to see government play some role believe government should help in reduc- in taking on the issue of obesity. ing obesity in the United States. Support for government role in combating obesity by income level % Government should have role385 Total 81 Less than $30,000/yr household 87 $30,000-$50,000/yr household 85 $50,000-$75,000/yr household 80 More than $75,000/yr household 77 C. MOST AMERICANS WANT TO MAKE COMBATING OBESITY A HIGH BUDGET PRIORITY Fifty-six percent of Americans support fund- African Americans are, by far, most likely to ing strategic government efforts to fight want government to make addressing obesi- obesity at all levels of government. This ty a priority in health budgets (81 percent includes majorities of most demographic support), with less support among both groups. Men, who are generally more reti- Hispanics (69 percent) and whites (52 per- cent about investing government resources, cent). Americans under the age of 50 also are as likely as women to support funding show greater interest in investing budget for this issue as a priority. funds to combat obesity (59 percent), com- pared to voters over 50 (53 percent). 87 D. STRONG SUPPORT EXISTS FOR IMPROVING STANDARDS IN SCHOOLS TO FIGHT CHILDHOOD OBESITY Americans do not believe schools provide a could take to help combat obesity, the pro- supportive environment for encouraging posals which received the most support were healthy behavior in children. Currently, less schools-based approaches: than one-third of adults (28 percent) think ■ Increasing physical education and activity that children participate in adequate in schools, including before and after amounts of physical activity during the school programs (71 percent rated as an school day, and just 32 percent think that 8 or higher on a 10 point scale). kids are engaging in enough physical activi- ty outside of school. Forty-eight percent of ■ Establishing higher nutritional standards adults say that lunches provided by schools for school lunches (66 percent rated as an are not nutritious enough, including a 8 or higher on a 10 point scale). majority of parents with kids under the age In addition, 60 percent of Americans favor a of 18 (55 percent). proposal to allow schools to measure each However, there is broad support for efforts student’s BMI annually and confidentially to improve the role of schools in promoting report the findings to his or her parents as a better health. Many Americans believe gov- way of bringing to light potential problems or ernment has a major role to play in combat- needs for changes. This includes 63 percent ing obesity through the schools. When of dads and 60 percent of moms. Only 36 asked about a series of actions government percent of Americans oppose the proposal. E. MOST ADULTS WANT GOVERNMENT TO HELP MAKE IT EASIER TO LIVE HEALTHY LIVES People express an awareness of the impor- ■ Expanding educational programs to tance of maintaining a healthy weight and reg- teach individuals about nutrition and ular exercise. They also see value in govern- healthy lifestyles (61 percent rated as an 8 ment playing a role in helping people achieve or higher on a 10 point scale). those standards as a means of reducing the ■ Providing free or low-cost access to exer- occurrence of obesity in the United States. cise and weight loss programs (59 percent Americans see a role for government in help- rated as an 8 or higher on a 10 point scale) ing to turn awareness into action, particular- ■ Reducing the marketing of unhealthy ly in the form of helping to provide strategies foods and increase the marketing of to increase physical activity and maintain a healthy foods (59 percent rated as an 8 or healthier diet in people’s daily lives. As men- higher on a 10 point scale). tioned earlier, the proposals receiving the most support focus on helping schools in the ■ Setting aside more green space in com- effort to combat childhood obesity. The pro- munities for parks and recreational areas posals that received the next strongest levels (54 percent rated as an 8 or higher on a of support center on actions government can 10 point scale). take to help individuals live healthier lives. 88 Proposals to help combat obesity % rating as an 8 or higher on a 10 point scale Increasing physical education and activity in schools, 71 including before and after school programs Establishing higher nutritional standards for school lunches 66 Expanding educational programs to teach individuals 61 about nutrition and healthy lifestyles Providing free or low-cost access to exercise and weight 59 loss programs Reducing the marketing of unhealthy foods and increase 59 the marketing of healthy foods Setting aside more green space in communities for parks 54 and recreational areas Expanding coverage for prevention, diagnosis and effective 50 treatments of obesity Building more sidewalks in neighborhoods and 43 communities to promote walking Strongest support for these measures tracks a healthy weight and exercise. Fifty-six per- with those most likely to see a role for gov- cent of adults under 30 and 63 percent of ernment in addressing the issue of obesity, those ages 30 to 49 recall getting such infor- including African American and Hispanic mation from their health care provider, adults, women, people with less than a col- while 69 percent of those over 50 heard lege education, and those with household from their doctor on the same topic. incomes of less than $50,000 a year. Doctors can help in the effort to fight the obesity epidemic and future health prob- Health care providers are also seen as playing lems by working to inform their patients a key part in educating the public about early about developing healthy habits. healthy living, and most Americans report that their doctors are talking to them about obesi- ■ Americans living in the Northeast and ty issues. Sixty-four percent say their doctor Western regions of the country are more talked about the importance of maintaining a informed about healthy living than their healthy weight during their last visit, while 66 counterparts in the Central and Southern percent say their physician mentioned the parts of the U.S.386 People living in the need for physical activity. At the same time, Northeast and West are more likely to cor- more than two-thirds of adults correctly iden- rectly identify the recommendations for tify the current CDC recommendation for moderate physical activity (70 and 73 per- moderate-intense physical activity as thirty cent respectively) compared to the South minutes a day on five or more days a week. (63 percent) and Central (68 percent) regions. In addition, Northeastern residents While majorities of Americans report knowl- are more likely to recall receiving informa- edge or receiving information from medical tion about keeping health from their doc- providers, there are differences within some tors (73 percent about weight management; demographic groups: 76 percent about physical activity) than peo- ■ Doctors provide less information to ple in other regions. (For weight manage- younger people about health risks and ment -- Central region: 65 percent; South: keeping healthy. Younger Americans, who 66 percent; West: 54 percent. For physical are less likely to be facing immediate health activity -- Central region: 64 percent; South: issues, are also least likely to have heard 66 percent; West 58: percent.) from their doctors about the importance of 89 ■ African Americans, most likely to have and keep active. Yet, these same people - heard information about keeping healthy - particularly senior citizens -- are less like- from doctors, are less informed on spe- ly to be able to cite the correct level of cific strategies for maintaining healthy recommended physical activity. weight and exercise regimens. Nearly 9- ■ Lower income Americans have less access in-10 African Americans recall their doc- to information from health professionals, tor talking about maintaining a healthy and consequently, less knowledge about weight (88 percent) during their last visit, how to maintain a healthy lifestyle. People and 85 percent recall a discussion on the living in households with incomes of less importance of participating in physical than $30,000 a year -- many of whom have activity. However, only 62 percent of less access to quality health care -- have the African Americans and Hispanic adults least knowledge about staying healthy answered with a correct knowledge of rec- and the needed level of physical activity. ommended levels of activity, compared Fifty-nine and 61 percent say their doctor with 71 percent of white adults. talked to them about the importance of a ■ Seniors also lack specifics on appropriate healthy weight and exercise, respectively, levels of physical activity. Older adults while 61 percent identified the recom- are most likely to hear from their doctors mended level of physical activity. about the need to manage their weight Information about obesity less accessible to lower-income Americans Total % % % % Under $30K- $50K- Over $30K $50K $75K $75K % Whose doctor discussed importance 64 59 70 71 62 of maintaining healthy weight % Whose doctor discussed importance 66 61 72 67 67 of physical activity % Who correctly identify recommended 68 61 67 76 76 levels of physical activity REGIONAL DEFINITIONS: Northeast: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, Delaware, New Jersey, New York, Pennsylvania. Central: Illinois, Indiana, Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, North Dakota, South Dakota, Nebraska. South: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Texas, Virginia, District of Columbia, Kentucky, Maryland, Oklahoma, Tennessee, West Virginia. West: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming, Alaska, California, Oregon, Hawaii, Washington. 90 Recommendations T he serious negative health and economic consequences of the obesity epidemic make the problem too important to ignore. Despite some increased attention on the issue, the continued rise in obesity rates causes 7 SECTION concern that the crisis is getting worse instead of better. The obesity epidemic is not going to get bet- Section 4: Promoting Physical Activity as a ter without a cultural shift in how the coun- Strategy to Improve Health of this report, try approaches the issue. even a little physical activity can have a big impact on improving people’s health. For too long, obesity and overweight have been considered an individual problem. TFAH’s top recommendations for combating When two-thirds of Americans are over- the obesity epidemic include: weight or obese and weight-related health care costs are compounding the nation’s sky- A. Improving Federal Leadership: National rocketing health care costs, this is clearly a Strategy; national problem. And for too long, the B. Fighting Obesity in the Workplace; focus of obesity prevention has been about appearance. The cultural emphasis needs to C. Helping All Americans Become More be changed away from “dieting” and appear- Physically Active; ance toward promoting healthy eating and D. Helping Americans Choose Healthier physical activity. The approach needs to Foods; and focus on encouraging lifestyle changes, even small ones, which can help people improve E. Accelerate and Escalate the Research into their health. For instance, as discussed in Ways to Promote Lifestyle Changes. 91 STATUS OF IOM’S 2005 RECOMMENDATIONS FOR CONFRONTING THE CHILDHOOD OBESITY EPIDEMIC FOR THE FEDERAL GOVERNMENT In 2005, the IOM issued a ground-breaking report Preventing Childhood Obesity: Health in the Balance to develop a prevention-focused action plan to decrease the prevalence of obesity in children and youth in the U.S. The report included a range of recommendations for different sectors, including 5 for the federal government. IOM Recommendation Status 1. Establishing an interdepartmental task No coordinated federal government effort force and coordinate federal actions has been established. 2. Developing nutrition standards for The 2007 reauthorization of the Farm Bill is foods and beverages sold in schools expected to update nutrition standards for school meal programs to meet the Dietary Guidelines for Americans, 2005. These guidelines focus on meeting minimum nutrition standards and are not expected to include standards for competitive foods and beverages. 3. Funding state-based nutrition and CDC’s school-based DASH grants average physical activity grants with strong only $416,000 and continue to be awarded evaluation components to only 23 states. VERB, a social marketing effort targeted at promoting physical activity in tweens that had proven positive results, has been defunded. 4. Developing guidelines regarding The FTC has held a conference to work with the advertising and marketing to food, beverage, and marketing industries. children and youth by convening a In July 2007, a number of prominent national conference companies announced voluntary self- regulation to limit marketing unhealthy food and beverage products to children under age 12. The federal government is not providing direct leadership over the effort and does not have a plan for evaluating the content of the ads or holding industry accountable. 5. Expanding funding for prevention Funding for prevention, experimental, and research, experimental behavior community-based population research has research, and community-based remained stagnant. population research; strengthen support for surveillance, monitoring and evaluation efforts. 92 A. IMPROVING FEDERAL LEADERSHIP: NATIONAL STRATEGY TO COMBAT OBESITY The federal government should develop and As part of the strategy: implement a National Strategy to Combat Obesity. ■ The nation’s health officials should articu- This plan should involve every federal govern- late federal government-wide responsibili- ment agency, define clear roles and responsibilities ties across multiple Departments (e.g. for states and localities, and engage private Health and Human Services, Transport- industry and community groups. ation, Agriculture, Education, Interior), Every segment of society has a role to play in provide specific responsibilities to states and fighting the epidemic, including families, localities, define expectations of the private health care providers, schools, businesses, sector, and develop detailed guidelines, and communities. Political will must be gal- action items, benchmarks, and timelines. vanized to make combating obesity a nation- ■ The federal government must provide sig- al priority at all levels of government. nificant funding for implementation of the State and local health departments should National Strategy to Combat Obesity. This convene diverse local leaders and members must include an investment to increase of the community to look for ways to pro- both scientific research to develop effective, mote physical activity and healthy eating, wide-scale public health solutions (see making information available and making Recommendation 3 for more detail) and to changes that help make it easier for people provide communities with the capacity and to make healthier choices. resources needed to make changes. The federal government needs to make a serious Our national leaders should give the crisis national commitment to this public health the attention it deserves by developing the crisis, instead of the fits-and-starts and fund- National Strategy to Combat Obesity. The ing-and-cutting pattern we have today. National Strategy for Pandemic Influenza Preparedness, with comprehensive govern- ■ Federal agencies must put forward clear, ment-wide responsibilities, clear timelines, consistent recommendations for nutri- and detailed action items, provides a strong tion and physical activity for individuals. example for how this type of effort could be Currently, CDC, NIH, and the Dietary undertaken. Obesity is as much of a threat Guidelines for Americans, 2005, all have to the public’s health as the looming possi- slight variations on physical activity rec- bility of a flu pandemic, and the nation must ommendations. Information about make a similar level of commitment by cre- healthy eating and activity should be con- ating a government-wide plan for addressing tained in a single set of clear guidelines the problem and providing the funding and promoted through high profile and needed to carry out the plan. ongoing public education efforts. 93 B. FIGHTING OBESITY IN THE WORKPLACE Federal, state, and local governments need to To accomplish this goal: work with private employers and insurers to a. Insurers should work with small- and ensure that every working American has access to medium-sized employers to provide pro- a workplace wellness program. grams that are affordable. Our national economic well-being requires that b. Federal, state, and local governments we engage every sector of society to promote should find ways to incentivize or encour- better nutrition and increased physical activity. age employers to provide workplace well- It is in everybody’s best interest to address the ness programs and preventive care cover- obesity crisis to help improve the economic age to their employees. vitality of our country. Obesity prevention, con- trol, and treatment need to become a primary c. Federal, state, and local governments focus for every sector of society. should be model employers, setting an example for private businesses and organ- The negative health consequences of inac- izations. tivity and poor nutrition are leading to a less productive U.S. workforce and exponential- d. Medicare, Medicaid, and SCHIP should ly driving up health care costs. It is in the update and increase obesity-related cov- economic interest of every employer and erage and reimbursement for preventive the nation as a whole to put a greater services (e.g. nutrition counseling and emphasis on keeping the workforce healthy physical activity programming) and set an and providing preventive care. example for private insurers. C. HELPING ALL AMERICANS BECOME MORE PHYSICALLY ACTIVE Research shows even small amounts of physical Steps to improve opportunities for physical activity can lead to major improvements in health. activity include: Americans must be given the tools they need to ■ Federal, state and local governments engage in more physical activity. In addition, need to make sure that physical educa- children should be given the opportunity to be more tion is part of the curriculum in every physically active throughout the day, both in and school. This includes eliminating barri- out of school. The communities we live in should ers to physical education, such as lack of allow greater opportunities for physical activity, quality teachers or insufficient funding. including places for safe and affordable public recreation and increased availability of sidewalks. ■ Schools should be encouraged to not only increase the amount of time students spend With the rise in childhood obesity, special in physical education classes but ensure that attention should be given to finding ways to enough time is actually being spent in mod- help young people to habitually make phys- erate-to-vigorous physical activity before and ical activity a part of their daily lives. after school and between classes. While schools and school districts are strug- ■ Schools and communities should ensure gling to meet set academic standards with that their environments are conducive to limited resources and time, physical educa- improving physical activity in children (e.g., tion is often being squeezed out. School establish safe routes to schools, work with design and community planning and devel- city or county to have well-marked crosswalks opment are also creating obstacles to physi- and sidewalks for safe walking and cycling). cal activity in everyday life. The need for physical activity should be incorporated into all planning for building new schools or remodeling existing schools. 94 D. HELPING AMERICANS CHOOSE HEALTHIER FOODS Americans must be given the tools to take Improving America’s nutrition requires the personal responsibility for their eating following steps: habits, including nutritional recommenda- ■ USDA should require all schools to meet tions, access to supermarkets, nutritional the Dietary Guidelines for Americans, 2005 information when they purchase food, and and should implement IOM nutrition stan- healthy food in schools. dards for “competitive foods” in schools. Addressing growing obesity rates is going to ■ Provide nutrition counseling as part of pre- require Americans to dramatically change ventive health services covered by insurance. their eating habits. Instead of periodically cut- ting calories or going on fad diets, individuals ■ Require restaurants and food companies need to develop healthy and balanced diets to to provide better and more readily acces- complement a more physically active lifestyle. sible information about the nutritional content of their products. Information about healthy eating and phys- ical activity should be promoted through ■ Implement an overall U.S. agricultural high profile and ongoing public education policy that works to improve Americans’ efforts. And, while the Dietary Guidelines for nutrition choices and increase opportuni- Americans, 2005 provide recommendations ties for fruit and vegetable consumption. for healthy eating, there needs to be greater ■ Improve access to healthy foods in all acknowledgement that the American diet is communities and schools, especially com- extremely different from those recommen- munities that face additional barriers dations, so greater effort needs to be made (e.g. lack of groceries stores). to bridge the divide. E. ACCELERATE AND ESCALATE THE RESEARCH INTO WAYS TO PROMOTE LIFESTYLE CHANGES Researchers know a lot about what consti- Some research about how to influence cul- tutes healthy nutrition and physical activity. tural behavior is underway at NIH, CDC, The challenge is finding ways to encourage and through measuring the success of real- people to make healthier decisions about world obesity prevention and control efforts diet and exercise that work on a wide-scale. -- but it is not enough to address the severity of this health threat. Researchers and practitioners have identi- fied a number of promising strategies that TFAH recommends that research into pub- have helped lead some to make choices to lic health interventions aimed at promoting change their behavior, such as offering improved nutrition and increased physical increased time for physical activity in activity be rapidly escalated and accelerated schools, providing nutritional information to meet the urgency of the crisis. in restaurants, and making healthy foods Intervention efforts with strong evaluation more accessible and affordable. components like CATCH and the recently defunded VERB program provide examples However, as obesity rates continue to rise in the for this type of research. U.S., there needs to be increased and strategic research about how to promote healthier TFAH has identified five major research habits more effectively and on a larger scale in questions that have not yet been adequately all communities. The level of investment in answered and could help provide break- research should reflect the level of threat obe- throughs in developing even more effective sity poses to our health and economy. obesity prevention and control strategies. 95 CHALLENGE TO THE RESEARCH COMMUNITY: FIVE MAJOR RESEARCH QUESTIONS 1) How does obesity relate to people’s health and life expectancy? Despite efforts by the CDC to study obesity, morbidity, and mortality, there are still many remaining questions about how obesity impacts health, contributes to diseases, and, in some cases, leads to death. 2) What is success: Can people be fit and fat or is weight loss necessary for good health? Research should examine the interrelationship between weight and activity. There are many questions about whether inactivity or weight has a bigger impact on health. These studies should explore how incremental changes in weight impact people’s health. Additionally, there are questions about how active Americans currently are versus how active they should be to maintain good health. These research efforts should also develop model physical educa- tion programs in schools and investigate the impact of community design on activity levels. 3) What are the relationships between socioeconomic and cultural issues and obesi- ty? This research should further examine the economics of eating healthy, including food accessibility and affordability, and racial/ethnic genetic and cultural differences. Improved understanding in these areas will lead to better intervention efforts within targeted populations. 4) What are the costs of obesity and the benefits of possible policy actions? There needs to be further research that clearly identifies the harms and costs caused by obesity and the potential health and economic benefits of anti-obesity efforts. Research should examine obesity prevention programs targeted at individuals, families, schools, communities, the food industry, employers, states, and the federal government. For example, more research is needed to study the impact of school nutrition and physical activity programs on academic outcomes, including school attendance, student behavior, and student achievement on standardized tests. 5) Who is responsible for obesity reduction? Research should examine if focusing on per- sonal responsibility is most effective or if approaches that include other factors that influence individual behavior lead to more positive results. There should also be efforts to develop bet- ter communication with the public about obesity recommendations and actions through con- sistent and effective messages targeted at appropriate audiences. F. TWENTY ACTION STEPS TO COMBATING OBESITY Stakeholders Recommendation Description Individuals and Personal Individuals Should Factor Health Concerns into Their Eating and Families: Responsibility Exercise Choices. Research has found that even small changes in diet and Programs physical activity can yield big results toward reducing people’s risk for health Eat and Exercise for problems, ranging from diabetes to heart disease. Everyone should Better Health regularly engage in some form of physical activity. Individuals should also adapt eating patterns toward healthier selections and limit their intake of foods with minimal nutritional value. People should also learn about and take advantage of resources designed to help them stay healthy. If they are unsatisfied with the support they receive, they should make their opinions known to their local, state, and federal government officials. Family Matters People Should Also Be Concerned About Obesity and Inactivity as Health Risks to Their Family Members. By encouraging family members to make healthy choices, people may help decrease the number of health problems their loved ones face. Particularly, by helping children stay active and maintain nutritious eating habits, families may help them avoid potential life-long diseases. Families also have leverage as consumers. They should directly communicate with food, beverage, and marketing industry and use their purchasing power to encourage product development and offerings that match the interest they may have for alternative choices. 96 Stakeholders Recommendation Description Communities and Healthy Provide Opportunities for Safe and Supervised Activity for Children. Local Governments: Environments in Communities should develop and support organizations and facilities that Community and allow children to participate in safe physical activity programs. Encourage and Faciliate Faith-Based a Healthy Lifestyle Organizations Provide No or Low Cost Physical Activity Opportunities and Nutrition Counseling. Communities should support offering no and low cost venues for children and adults to participate in physical activity, ranging from building and maintaining parks to supporting community centers, such as YMCAs. Community groups should also provide access to no or low cost physical activity programs. Offer Healthy Food at Community Events. Communities should provide nutritious food at events to help people foster and maintain healthy eating habits. Focus on Smarter Provide Improved Healthy Food Access in Low-Income Areas. Community Design Healthy food access is a demonstrated problem in many low-income communities. Communities should encourage the development of and provide public space for locally-operated produce markets and farmers markets. Also, through the use of incentives, communities should encourage supermarkets and food shopping vendors to locate in lower-income neighborhoods and offer healthier food alternatives. Encourage “Mixed Use” Areas. Communities and states should examine and update zoning and land use laws to allow for more “mixed use” commercial and residential communities, so people can have more opportunities to walk or bike to retail centers and to work. Examine Health Impact of New Building. Communities should require “Health Impact Assessments” for proposed land use and building projects, which will help communities and policymakers understand the possible resulting changes to people’s health, including access to recreational space and to food shopping. These can be based on the “Environmental Impact Assessment” model. Building Design Codes. Encourage new building design that includes stair-friendly and other spaces that facilitate activity in commercial and public buildings. Encourage Greenspace Development and Build More Sidewalks. Prioritize and incentivize increased green space development through the collaboration of public health and transportation entities in states. Communities should also place greater emphasis on building well-lit sidewalks and paths, particularly in new developments and around highways, to make it possible for people to walk safely. Encourage Transportation Fund Use for Mass Transit and Alternatives to Highways. Communities should insist that states and counties require alternative proposals be examined when new highway initiatives are proposed. New development should also be required to include pedestrian-friendly components, such as sidewalks, which encourage interconnectivity of communities and opportunities for activity. State and federal transportation dollars should be considered for mass transit, sidewalk, and mixed use opportunities rather than be focused on highway construction. 97 Stakeholders Recommendation Description Communities and Healthy Modernize New School-Site Construction Requirements. States and Local Governments: Environments in localities should review and update old acreage requirements for new school Community and construction that required large spaces for construction, but have ended up Encourage and Faciliate Faith-Based resulting in the building of schools in remote locations that students can often a Healthy Lifestyle Organizations only access by bus rather than by walking or biking. Flexible standards for school site construction would allow communities to build schools closer to existing homes and commercial regions instead of in remote areas. Governors, Obesity Research Community-Wide Education Campaigns. Communities and states Legislators, and and Prevention should create or expand initiatives to inform the public about ways to State Health Initiatives maintain better health, particularly for groups that are at-risk for obesity- Departments: related diseases and for children. These efforts should include developing practical, effective, and consistent messages to help avoid confusion. In Oversee and addition, efforts to mobilize communities around physical activity, nutrition Implement Creative policy, and environmental change using evidence-based practices should Policies be supported. Employer Status and State and Local Government Employee Wellness Efforts. State and Purchasing Clout local governments are employers as well as providers of governance and public service. Many Governors have begun initiatives to provide workplace wellness, preventive health care services, including premium discounts, subsidies for fitness clubs and activities, disease management programs, and information to state employees, such as nutrition, physical activity, and obesity counseling. All states should offer these programs and should also provide these models to private businesses to expand these opportunities to private employees as well. Leverage Power as Food Purchaser. The public sector purchases food across a range of institutions, including in government cafeterias, schools, and prisons. The government should leverage its power as a food purchaser to require a greater emphasis on nutritional value as a priority in the bidding process for these contracts. Evaluate Current Snack Tax and Liability Limitation Policies. States should devote time and resources to developing evaluation standards to monitor the effectiveness of both types of controversial initiatives. Schools and Taking Responsibility Adopt Higher Nutritional Standards Than USDA. Some states have School Districts: for Feeding taken the lead in setting requirements that are higher than the USDA Students Well minimum requirements for food served in school. Instead of focusing on Educating Healthy delivering minimum nutritional standards, schools and school districts Minds and Bodies... should concentrate on setting high nutritional standards for the foods served “Minimum” Standards to students that allow them to eat for better health. These standards Are Not Good Enough should be extended to cover “competitive” foods as well as those sold during the regular meal program. Revise Food Contract Policies and Priorities to Focus on Maximum Nutrition. Contracts for school food suppliers and providers should be reviewed to focus on competing to provide maximum nutrition standards to students. 98 Stakeholders Recommendation Description Schools and Taking Responsibility Evaluate Alternative Fundraising Options that Do Not Involve School Districts: for Feeding Providing Food of Minimum Nutritional Value to Students. Students Well Currently many schools, school districts, and after-school activities rely on Educating Healthy revenue from vending machines and other food sales. Jurisdictions should Minds and Bodies... conduct cost-benefit analyses of these funds, factoring in the impact and “Minimum” Standards cost to children’s health. Communities must be better informed that while Are Not Good Enough revenue from “competitive foods” may seem like an effective fundraising mechanism, it also directly results in a reduction in federal funds to the school lunch program. Communities should prioritize finding other revenue streams to support programs or offer more healthful items for sale. Evaluate and Refine BMI Initiatives. School BMI screening programs should be evaluated for effectiveness for reducing and controlling obesity. Schools in which BMI data is collected should establish clear and consistent evaluation standards to ensure that success can be measured. Fitness and Activity Physical Education Should Be Incorporated into No Child Left Behind During the Day Requirements. While schools and school districts are struggling to meet set academic standards with limited resources and time, physical education still needs to be considered an important part of a child’s education. Additional emphasis must also be placed on training and maintaining expertly qualified physical education teachers. Schools should also encourage other activity throughout the day and ensure that facilities and space for students provide options for walking, being active, and exercising before and after school as well as between classes. Improve Nutrition and Health Promotion Education. Greater efforts should be made to educate students about ways to maintain good nutrition and exercise regimes and how this impacts their health. Employers: Wellness and Offer Employees Programs and Health Benefits that Help Them Stay Disease Prevention Healthy, including nutrition, physical activity, and obesity counseling, Healthy Workers Are Programs and subsidizing health club memberships, and providing insurance discounts for Productive Workers; Benefits preventive services. Investing in the health of employees not only improves Jumpstart American productivity but also cuts down on absenteeism. A national forum should be Competitiveness established for employers to share best practices in worksite wellness and to foster connections between smaller employers to promote economies of scale to offer wellness benefits. Healthier Work Provide Opportunities for Employees to be Active During the Day, Environments including open, safe stairwells and other places to walk. Businesses should also focus on providing healthy options in vending machines and in cafeterias. Industry: Health Care Sector Promote Prevention Efforts in the Marketplace. Offering more Encourage Healthy prevention-focused benefit options to employers could improve long-term Options, Prevention, health and make an economic difference. This should extend to providing and Informed Choice prevention support and offering healthy food and activity capabilities to their in the Marketplace own employees as well. Routinely Measure Patients’ Exercise Histories. As part of a normal check up, health care providers should routinely ask patients about their exercise his- tories and habits and counsel patients on the importance of fitness for their health. Food, Beverage, and Encourage Healthy Options and Inform Customers. Providing customers Marketing Industries with healthy options and additional product information and nutritional values can be good for both health and the bottom line. The food and beverage industry should provide consistent nutritional labeling to consumers, based on product size. Industry should seek the input of parents and other community members to establish standards and practices for marketing products to children. 99 Stakeholders Recommendation Description Federal Government: Update Agricultural Include Obesity Prevention-Focused Initiatives in the Farm Bill. Raising the Bar for Policy to Encourage The Farm Bill could impact a wider range of other policies related to Coverage and Updating Healthy Eating schools, the Food Stamp Program, farmers’ markets, and farm subsidies Nutrition Standards for fruits and vegetables. The Food Stamp and WIC Programs should Focus on Maximum Nutrition for Cost. At a minimum, the programs should be adapted to meet the new IOM recommended opportunities to private employees as welld up resulting the building of schools in remote locations that studefed- eral food guidelines. More should be done to enable healthier food choice, such as purchasing fresh fruits and vegetables, decreasing fat, and increasing whole grain foods. Greater actions should be taken to provide useful nutritional counseling and services. Improve Obesity- Provide Routine Screenings for Those At-Risk for Obesity-Related Related Coverage in Illnesses. Individuals in lower-income ranges, including many who are in Medicaid & SCHIP the Medicaid program, are at high risk for obesity and many obesity-related diseases. The current Medicaid reform efforts should mandate routine screenings for program participants along with routine nutritional and obesity counseling. Better prevention and disease management programs will result in cost savings to the system as a whole. Provide Obesity-Related Services in the Children’s Health Insurance Program (SCHIP). The SCHIP program should be updated to provide obesity-related medical advice, counseling, and treatment. Subsidize or Reimburse for Fitness Programs. Providing support for individuals receiving Medicaid to participate in exercise and fitness programs, such as those offered by the YMCA or community recreational centers, will help reduce beneficiaries’ risk for developing or better manage obesity- related diseases, as well as improve the health of those who are already suffering from related diseases. Raise Requirements Minimum Nutrition Standards Should Be Raised. The USDA school on School Meal lunch program not only influences school food offerings through Programs and requirements for the formal meal programs, but also serves as a model. Increase Access to The standards should be reformed to focus on providing maximum nutrition Healthy Foods rather than minimum nutrition to students. At a minimum, the standards should be raised to match the Dietary Guidelines for Americans, 2005. Increase Access to Fruits and Vegetables in Schools. Provide greater funding for the Fresh Fruit and Vegetable Program, the DOD Fresh Program, and farm-to-cafeteria programs that encourage healthy eating among school children. Fix the Food Address Public Concerns. There were a number of public concerns that Pyramid and Add were unaddressed after the new food pyramid guidelines were released Corresponding earlier this year. USDA should make every effort to respond to concerns Physical Activity that ranged from complaints that the spectrum of pyramids was too Guidelines confusing to information only being available online to insufficient information about unhealthy foods and serving sizes. Add More Physical Activity Information. The new food pyramid included encouraging individuals to engage in activity for the first time. This should be expanded into providing a full-fledged set of guidelines and recommendations to the public on physical activity. These should be consistent across government agencies and promoted through major public education initiatives. 100 Stakeholders Recommendation Description Offer and Emphasize As an Employer, the Federal Government Should Provide Preventive Prevention Benefits Health Services. The federal government should set an example and place Provided to Federal a high priority on providing obesity and nutrition counseling, preventive Employees health programs, proactive disease management benefits, and premium discounts for preventive services to federal employees. Use Clout as Food Government has a Critical Role as Employer Model and Purchaser. Purchaser, Employer, The government purchases food for a range of purposes, ranging from and Service Provider USDA programs to cafeteria food for employees to veterans hospitals to to Veterans meals for the military. Government should serve as a model in following high nutrition guidelines for the meals and food it provides, as well as using its clout to influence the food industry to provide healthier choices to consumers. The government should also explore incentive programs for food companies to make healthier food available, especially directed to targeted populations. Bolster Obesity Prioritize and Fund Key Research Initiatives. Based on the size, cost, Research and impact of the obesity issue, the federal government should prioritize and fully fund critical research efforts, particularly the five major research questions TFAH outlined that are holding back the ability to make better informed and practical policies. Expand the Behavioral Risk Factor Surveillance System (BRFSS). Currently, the primary source for trends on health information, BRFSS, is not receiving adequate resources. If the survey were to receive additional resources, the information could better inform policy decisions and allow for more research to be conducted on trends and provide accountability and measures for policy initiatives. Explore Economic Incentives for Promoting Good Nutrition and Physical Activity. The federal government should sponsor research and modeling efforts on the use of economic incentives to encourage businesses to provide more healthy options to consumers, such as examining the impact of taxes on unhealthy foods or subsidies for fruit and vegetable marketing. Increase Availability Expand and Fully Fund Obesity-Related Initiatives. Currently, there of Obesity-Initiatives are insufficient funds allocated to provide grants for existing obesity programs and Grants to States to meet the requests of states. At a minimum, there should be enough funding to provide grants to all qualified state applicants to the CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) and the school-based Division of Adolescent and School Health (DASH) grant programs. Enhance Targeted Public Education Efforts, Particularly for Children. The IOM has called for the increased use of media as a channel to reach and inform children about nutrition and exercise. Public education campaigns aimed at high-risk communities should be developed using consistent messages. CDC had a program called VERB which has been defunded, was a multiethnic, multimedia education campaign targeted at youth ages 9 to 13 that encouraged more physical activity and increased the awareness of the importance of exercise and demonstrated positive results. In a new program, the FDA is partnering with Time Warner’s Cartoon Network to launch a media campaign that encourages “tweens” ages 9 to 13 to make healthy eating decisions. The Spot the Block campaign will teach tweens to read nutrition labels on food packages and make more informed dietary choices. 101 APPENDIX A: METHODOLOGY FOR OBESITY AND OTHER RATES USING BRFSS Data for this analysis was obtained from the no clustering of sampled elements. Behavioral Risk Factor Surveillance System Omission of the sample weight implies (BRFSS) dataset (publicly available on the web equally weighted sample elements. Mean at www.cdc.gov/brfss). The analysis was con- proportions for each variable were estimated ducted by Daniel Eisenberg, PhD, and Edward using the svy: proportion command. N. Okeke MBBS, of Department of Health Variables of interest included BMI, physical Management and Policy of the University of inactivity, hypertension, and diabetes. BMI was Michigan School of Public Health. calculated by dividing self-reported weight in BRFSS is an monthly cross-sectional survey kilograms by the square of self-reported designed to measure behavioral risk factors height in metres. Obesity was then defined as in the adult population (18 years of age or calculated BMI greater than or equal to 30 older) living in households. Data are col- and overweight was defined as calculated BMI lected from a random sample of adults (one greater than or equal to 25 but less than 30. per household) through a telephone survey. For the physical inactivity variable a binary The BRFSS currently includes data from 50 indicator equal to one was created for adults states, the District of Columbia, Puerto Rico, who reported not engaging in physical activity Guam, and the Virgin Islands. The most or exercise during the previous thirty days recent data available was 2006. other than their regular job. For diabetes, ana- lysts created a binary variable equal to one if To account for the complex nature of the sur- the respondent reported ever being told by a vey design and obtain estimates accurately doctor that he/she had diabetes. representative at the state level, we used sam- ple weights provided by the CDC in the We calculated rolling 3 year averages, first by dataset. The main purpose of weighting is to averaging data from 2003-2005 and then by reduce bias in population estimates by up- averaging data from 2004-2006 (after merg- weighting population sub-groups that are ing data from the relevant time period). We under represented and down-weighting those report mean proportions for each 3-year peri- that are over represented in the sample. od as well as standard errors and 95 percent confidence intervals for all variables of inter- We specified the sampling plan to STATA387 est. In addition we carried out a Pearson sta- using the svyset command and the following tistical test of proportions and report which set of weights: sample weight variable states experienced a significant increase or (FINALWT), first-stage stratification variable decrease (significant at the 95 percent level). (STSTR), and primary sampling unit vari- able (PSU). Omission of the stratification The 2003-2005 sample consisted of 923,811 variable in STATA implies no stratification of observations while the 2004-2006 sample PSUs prior to first-stage sampling. Omission consisted of 1015644 observations. We of the primary sampling unit variable excluded all observations with missing val- implies one-stage sampling of elements and ues from the analysis.388 103 APPENDIX B: RESPONDENTS TO TFAH’S SURVEY OF CHRONIC DISEASE DIRECTORS AND DIRECTORS OF HEALTH PROMOTION AND EDUCATION State Chronic Disease Directors 33 total respondents: 28 listed below, 5 chose to remain anonymous Cherrie Bartlett Mary Manning Administrator for Chronic Disease Prevention Division Director, Health Promotion & Missouri Department of Health & Senior Services Chronic Disease Patti Baum Minnesota Department of Health Health Promotion Manager Paula Marmet New Hampshire Division of Public Health Services Director, Office of Health Promotion Cynthia Boddie-Willis Kansas Department of Health and Environment Director, Division of Health Promotion and Chandana Nandi Disease Prevention Chief, Division of Chronic Disease Massachusetts Department of Public Health Illinois Department of Public Health Michael Byrd Sue Percifield Director, Bureau of Community Health Director, Chronic Disease South Carolina Department of Health and Indiana State Department of Health Environmental Control Marcus Plescia Carol Callaghan Chief, Chronic Disease and Injury Chronic Disease Director North Carolina Division of Public Health Michigan Department of Community Health Diane Roberts Ayers Gerrelda Davis Nutrition and Physical Activity Coordinator Acting Chronic Disease Director Georgia Division of Public Health Louisiana Department of Health and Hospitals Jennifer Smith Joseph Grandpre Manager, Adult Health and Chronic Chronic Disease Section Chief & Deputy State Disease Group Epidemiologist Texas Department of State Health Services Wyoming Department of Health Victor D. Sutton Dennis Haney Director, Office of Preventive Health Community Health Consultant Mississippi Department of Health Iowa Department of Public Health Tom Tracy, Manager and Jaime Hineman, Health Jack Hataway Program Specialist Chronic Disease Prevention Office Director Physical Activity and Nutrition Program Alabama Department of Public Health Idaho Department of Health and Welfare Donna Henry* David Vigil Director, Health Promotion Division Chronic Disease Director Tennessee Department of Health New Mexico Department of Health Charlene Herst Virginia Warren Manager, Chronic Disease Section Section Manager for Chronic Disease Nevada State Health Division Arizona Division of Public Health Services Phil Huang Ann Weidenbenner Medical Director, Chronic Disease Prevention CVH Program Administrator Texas Department of State Health Services Ohio Department of Health Janet C. Luttrell Sharon A. Williams Manager, Chronic Disease Prevention & Control Director of Chronic Disease Prevention Branch US Virgin Islands Department of Health Kentucky Department for Public Health Barbara Yamashita Donald Lyman, MD Chief, Community Health Division Division Chief Hawaii State Department of Health California Department of Health Services 104 State Directors of Health Promotion and Education 21 total respondents: 18 listed below, 3 chose to remain anonymous Eydie Abercrombie Dr. Jim McVay Physical Activity Section Chief Director Health Promotion & Chronic Disease Arkansas Department of Health Alabama Department of Public Health Don Bishop Jane Moore Chief, Center for Health Promotion Health Promotion & Chronic Disease Minnesota Department of Health Prevention Manager Oregon Department of Human Services Ninia Baehr Program Manager, MT Nutrition and Physical Donna Nichols Activity Program Senior Prevention Policy Analyst Montana Department of Public Health and Texas Department of State Health Services Human Services Mary Pesik Janet Baggett Nutrition and Physical Activity Program Deputy Chief, Bureau of Chronic Disease, Coordinator Prevention & Health Promotion Wisconsin Department of Health and Family Florida Department of Health Services Christina Carrillo Ramona Dawn Schaeffer Director, Office of Health Promotion and Director, Division of Chronic Disease Prevention Community Health Improvement and Control New Mexico Department of Health Virginia Department of Health Linda Chasson Thomas J. Schafer Preventive Health and Safety Division, Acting Deputy Director, Office of Health Administrator Promotion Wyoming Department of Health Illinois Department of Public Health Dan Cillessen Jane Sims Administrator, Office of Health Promotion Project Coordinator Nebraska Health and Human Services Utah Department of Health Jennifer Dunlap Maxene Spolidoro Director, Office of Public Affairs Health Communications Director, Division of Indiana State Department of Health Health Promotion and Disease Prevention Massachusetts Department of Public Health Donna Henry* Director, Division of Health Promotion * Respondent provided answers under both the CDD Tennessee Department of Health and DHPE survey. Rose Marie Matulionis Executive Director Directors of Health Promotion and Education 105 Endnotes 8 Ibid. 9 S. Squires, “One Number Doesn’t Fit All,” Washington Post, 5 July 2005. 1 See Section 7 of the report for more details. 10 Ibid. 2 National Institutes of Diabetes and Digestive and Kidney Diseases, Weight-control Information 11 Ibid. Network, “Do You Know the Health Risks of 12 S. Squires, “One Number Doesn’t Fit All,” Being Overweight?” November 2004, Washington Post, 5 July 2005. http://win.niddk.nih.gov/publications/health_ri sks.htm; and U.S. Centers for Disease Control 13 “Expert Committee Recommendations on the and Prevention, “Overweight and Obesity Assessment, Prevention, and Treatment of Child Consequences,” http://www.cdc.gov/nccdphp/ and Adolescent Overweight and Obesity,” 6 June dnpa.obesity/consequences.htm. 2007, http://www.ama-assn.org/ama1/pub/ upload/mm/433/ped_obesity_recs.pdf. 3 U.S. Federal Trade Commission, Weight-Loss Advertising: An Analysis of Current Trends 14 National Center for Health Statistics, Centers (Washington, DC: U.S. Federal Trade for Disease Control and Prevention, “Obesity Commission, September 2002). Still a Major Problem,” Press Release, 14 April 2006, http://www.cdc.gov/nchs/pressroom/ 4. Government agencies, foundations and researchers 06facts/obesity03_04.htm. often use different terms to describe obesity in chil- dren and adolescents. The Robert Wood Johnson 15 U.S. Department of Health and Human Foundation uses the term “obese” for children and Services, Health Resources and Services adolescents who have a body mass index (BMI) at Administration, Maternal and Child Health or above the 95th percentile for their gender and Bureau, Overweight and Physical Activity Among age. We use the term “overweight” for children Children: A Portrait of the States and the Nation and adolescents with a BMI at or above the 85th 2005, Technical Appendix, percentile but below the 95th. The Institute of http://www.mchb.hrsa.gov/overweight/techap Medicine also uses the term “obese” to describe p.htm (17 July 2007). children and adolescents at or above the 95th per- 16 U.S. Centers for Disease Control and Prevention, centile but uses the term “at risk for obesity” to “Youth Risk Behavior Surveillance - United States describe those with BMI at or above the 85th per- 2005,” MMWR Surveillance Summaries 55, no. SS-5 centile but below the 95th. The Centers for (9 June 2006). Disease Control and Prevention uses the term 17 U.S. Centers for Disease Control and “overweight” for those at or above the 95th per- Prevention, Behavioral Risk Factor Surveillance centile and "at risk of overweight” for children and System Survey Data (Atlanta, GA: U.S. Centers for adolescents at or above the 85th percentile but Disease Control and Prevention, 2006). below the 95th percentile. ; “Resident Population Projections by Sex and Age 2005 to 2050.” U.S. 18 U.S. Centers for Disease Control and Census Bureau, Statistical Abstract of the United Prevention, Behavioral Risk Factor Surveillance States, 2006. Table 12. http://www.census.gov/ System Survey Data (Atlanta, GA: U.S. Centers for prod/2005pubs/06statab/pop.pdf.; Ogden CL, Disease Control and Prevention, 2005). Carroll MD, Curtin LR, McDowell MA, Tabak CJ 19 This analysis examines a correlation, not a and Flegal KM. 2006. “Prevalence of Overweight causal relationship. There are 4 potential and Obesity in the United States, 1999-2004.” explanations for the observed relationship. 1) Journal of the American Medical Association, 295 Lack of exercise causes obesity; 2) Obesity caus- (13):1549-1555. es people to exercise less; 3) An unobserved 5 U.S. Centers for Disease Control and Prevention, third factor is causing both obesity and lack of National Center on Vital Statistics, Health, United exercise; 4) A combination of any or all of the States, 2003 (Atlanta, GA: Centers for Disease three previous reasons. Control and Prevention, 2003). 20 M. Ezzati et al., “Trends in National and State- 6 U.S. Centers for Disease Control and Prevention, Level Obesity in the USA After Correction for Self- National Center on Vital Statistics, Health, United Report Bias: Analysis of Health Surveys,” Journal of States, 2003 (Atlanta, GA: Centers for Disease the Royal Society of Medicine 99 (May 2006). Control and Prevention, 2003); and J.S. Schiller 21 M. Bayard, “State Employee Wellness Initiatives,” et al., “Early release of selected estimates based National Governors Association Center for Best on data from the January-September 2005 Practices, June 2005, http://www.nga.org/cda/ National Health Interview Survey,” National files/05WELLBRIEF.pdf (11 July 2005). Center for Health Statistics, http://www.cdc.gov/ 22 National Governors Association Center for Best nchs/nhis.htm (30 May 2006). Practices, “Healthy States Grant Program. Healthy 7 A.J. Stunkard and T.A. Wadden (Editors), America: Wellness Where We Live, Work and Obesity: Theory and Therapy (Second Edition) Learn,” 4 January 2007, http://www.nga.org/ (New York: Raven Press, 1993); and Diet and portal/site/nga/menuitem.9123e83a1f6786440d Health: Implications for Reducing Chronic Disease dcbeeb501010a0/?vgnextoid=a12c67f71c1bc010V Risk (Washington, DC: National Academy Press, gnVCM1000001a01010aRCRD (9 July 2007). 1989). 106 23 National Governors Association Center for Best 40 “The Regulation to Phase Out: Artificial Trans Practices, “Healthy Kids, Healthy America,” 30 Fat,” www.citytech.cuny.edu/notransfatnyc/eng- March 2007, http://www.nga.org/portal/site/ lish/faqs.html (10 July 2007). nga/menuitem.9123e83a1f6786440ddcbeeb501 41 P.J. Veugelers and A.L. Fitzgerald, “Effectiveness 010a0/?vgnextoid=a5b1bac351071110VgnVCM1 of School Programs in Preventing Childhood 000001a01010aRCRD (9 July 2007). Obesity: A Multilevel Comparison,” American 24 National Governors Association, “Healthy Journal of Public Health 95, no. 3 (2005). States: State of Colorado,” http://www.nga.org/ 42 C. Stefkovich, Administrator, Nutrition Services, Files/pdf/0703HEALTHYSTATESCO.PDF. Nebraska Department of Education, “Clarification 25 National Governors Association, “Healthy States: of the Competitive Food Policy,” Memo, June State of Connecticut,” http://www.nga.org/ 2006, http://www.nde.state.ne.us/NS/forms/ Files/pdf/0703HEALTHYSTATESCT.PDF. nslpforms/Comp_Memo_04.pdf (5 August 2007). 26 National Governors Association, “Healthy States: 43 “School Health Profiles,” brochure. State of Georgia, Live Healthy Georgia Learning <http://www.cdc.gov/healthyyouth/profiles/ Laboratory Project,” http://www.nga.org/Files/ brochure.htm> 31 July 2007. pdf/0703HEALTHYSTATESGA.PDF. 44 U.S. Government Accountability Office, School 27 National Governors Association, “Healthy States: Meal Programs, Competitive Foods Are Available in State of Iowa,” http://www.nga.org/Files/pdf/ Many Schools; Actions Taken to Restrict Them Differ 0703HEALTHYSTATESIA.PDF. by State and Locality, GAO Report-04-673 28 National Governors Association, “Healthy States: (Washington, DC: U.S. Government State of Maine,” http://www.nga.org/Files/pdf/ Accountability Office, April 2004). 0703HEALTHYSTATESME.PDF. 45 Ibid. 29 National Governors Association, “Healthy States: 46 “School lunch prices on the rise; efforts to offer State of Michigan,” http://www.nga.org/Files/ healthier food continue,” The Food Institute pdf/0703HEALTHYSTATESMI.PDF. Report 16 (August 2004); Physicians Committee 30 National Governors Association, “Healthy States: for Responsible Medicine, School Lunch Report State of Minnesota,” http://www.nga.org/Files/ Card (Washington, DC: Physicians Committee pdf/0703HEALTHYSTATESMN.PDF. for Responsible Medicine, August 2004); “Obstacles in Way of Healthy School Lunch,” 31 National Governors Association, “Healthy States: Associated Press Online, 7 December 2003; and State of Nebraska,” http://www.nga.org/Files/ U.S. Government Accountability Office, School pdf/0703HEALTHYSTATESNE.PDF. Meal Programs, Competitive Foods Are Available in 32 National Governors Association, “Healthy States: Many Schools; Actions Taken to Restrict Them Differ ‘Make it Your Business’ for a Strong & Healthy by State and Locality, GAO Report-04-673 Oklahoma - Business Partnership Campaign,” (Washington, DC: U.S. Government http://www.nga.org/Files/pdf/ Accountability Office, April 2004). 0703HEALTHYSTATESOK.PDF. 47 Center for Health and Health Care in Schools, 33 National Governors Association, “Healthy States: “USDA Cautions on School Food Contracts,” State of South Dakota,” http://www.nga.org/ Health and Health Care in Schools 5, no. 11 (January Files/pdf/0703HEALTHYSTATESSD.PDF. 2005), http://www.healthinschools.org/ ejournal/2005/jan1.htm. 34 National Governors Association, “Healthy States: State of Utah,” http://www.nga.org/Files/pdf/ 48 U.S. Government Accountability Office, School 0703HEALTHYSTATESUT.PDF. Meal Programs, Competitive Foods Are Available in Many Schools; Actions Taken to Restrict Them Differ 35 National Governors Association, “Healthy States: by State and Locality, GAO Report-04-673 State of Washington,” http://www.nga.org/Files/ (Washington, DC: U.S. Government pdf/0703HEALTHYSTATESWA.PDF. Accountability Office, April 2004). 36 National Governors Association, “Healthy States: 49 S. Squires, “Give Kids a Chance to Eat Wisely,” State of Wisconsin,” http://www.nga.org/Files/ Washington Post, 24 April 2007. pdf/0703HEALTHYSTATESWI.PDF. 50 Institute of Medicine, “Nutrition Standards for 37 “The Regulation to Require Calorie Labeling on Foods in Schools - Leading the Way Toward Menus In New York City Food Service Establish- Healthier Youth,” Report Brief, April 2007, ments,” Section 81.50 of the New York City http://www.iom.edu/Object.File/Master/42/50 Health Code, http://home2.nyc.gov/html/doh/ 5/Food%20in%20Schools.pdf. downloads/pdf/cdp/cdp-pan-calorie-bro.pdf (10 July 2007). 51 Institute of Medicine, Nutritional Standards for Foods in Schools: Leading the Way Toward Healthier 38 R. Rivera, “Enforcement of Calorie-Count Rule Youth (Washington, D.C.: National Academies Is Delayed,” New York Times, 20 June 2007. Press, 2007). 39 The New York City Department of Health and 52 S. Squires, “Panel Urges Schools To Replace Mental Hygiene, “Health Department Launches Junk Foods,” Washington Post, 26 April 2007. Trans Fat Help Center to Support Resturants in Going Trans Fat Free,” Press Release #022-07, 5 April 2007, http://www.nyc.gov/html/doh/html /pr2007/pr022-07.shtml (10 July 2007). 107 53 Institute of Medicine, “Nutrition Standards for 68 C. Hulse, “Vote in House Offers a Shield in Foods in Schools - Leading the Way Toward Obesity Suits,” New York Times, 11 March 2004. Healthier Youth,” Report Brief, April 2007, 69 M.F. Jacobson, “‘Big Food’ to Win Special http://www.iom.edu/Object.File/Master/42/50 Protection in House of Representatives,” Center 5/Food%20in%20Schools.pdf. for Science in the Public Interest, 10 March 54 C.E. Mayer, “Sugary Drinks To Be Pulled From 2004, http://www.cspinet.org/new/ Schools: Industry Agrees to Further Limit Avail- 200403102.html (15 September 2004). ability to Children,” Washington Post, 3 May 2006. 70 T. Breen, “Beset by obesity-related costs, W.Va. 55 William J. Clinton Foundation, “Alliance for a turns to Weight Watchers,” Associated Press, 27 Healthier Generation - Clinton Foundation and January 2007. American Heart Association - and Industry 71 National Governors Association Center for Best Leaders Set Healthy School Beverage Guidelines Practices, “Issue Brief: Creating Healthy States; for U.S. Schools,” Press Release, 3 May 2006, Promoting Healthy Living in the Medicaid http://www.clintonfoundation.org/050306-nr-cf- Program,” 5 August 2006, http://www.nga.org/ hs-hk-usa-pr-healthy-school-beverage-guidelines- Files/pdf/0608CREATINGHEALTHYS- set-for-united-states-schools.htm. TATESMEDICAID.PDF 56 “Press Release: Alliance for a Healthier Gener- 72 Ibid. ation - Clinton Foundation and American Heart Association - and Industry Leaders Set Healthy 73 Ibid. School Beverage Guidelines for U.S. Schools,” 74 T. Breen, “Beset by Obesity-Related Costs, W.Va. Clinton Foundation. (New York, NY: 3 May 2006) Turns to Weight Watchers,” Associated Press, 27 < http://www.clintonfoundation.org/ 050306-nr- January 2007. cf-hs-hk-usa-pr-healthy-school-beverage-guidelines- 75 Ibid. set-for-united-states-schools.htm> 3 May 2006. 76 State Coverage Initiatives, The Robert Wood 57 Ibid. Johnson Foundation, “Coverage Profile: West 58 The Alliance for a Healthier Generation, Virginia,” October 2006, http://www.statecover- www.healthiergeneration.org. age.net/profiles/westvirginia.htm (11 July 59 Alliance for a Healthier Generation, 2007). “Guidelines for Competitive Foods Sold in 77 K.L. Nelson, “Not a Loss; TennCare-Weight Schools to Students,” http://www.healthiergen- Watchers Pilot Seems Successful So Far,” eration.org/uploadedFiles/For_Schools/snack- Knoxville News-Sentinel, 17 July 2006. food-guidelines.pdf (30 July 2007). 78 T. Breen, “Beset by Obesity-Related Costs, W.Va. 60 Ibid. Turns to Weight Watchers,” Associated Press, 27 61 “Guidelines for School and Community January 2007. Programs to Promote Lifelong Physical Activity 79 “Colorado Medical Assistance Act: House Bill 05- Among Young People,” MMWR 46, no. RR-6 (7 1066,” http://www.state.co.us/gov_dir/leg_dir/ March 1997). olls/sl2005a/sl_164.pdf, 2005. 62 National Governors Association Center for Best 80 Woodrow Wilson School of Public and Inter- Practices, “The Obesity Epidemic - How States national Affairs, “The Future of Children,” Spring Can Trim the ‘Fat,’” 13 June 2002, 2006, http://www.futureofchildren.org/usr_doc/ http://www.nga.org/center/divisions/1,1188,C Obesity_Volume_16,_Number_1_Spring_2006.pdf. _ISSUE_BRIEF^D_3878,00.html (29 July 2004). 81 Nebraska Department of Social Services Manual, 63 World Health Organization, “Global Strategy on “Chapter 33-000 HEALTH CHECKS and Diet, Physical Activity and Health,” May 2004, Treatment Services for Conditions Disclosed http://www.who.int/ (12 July 2005). During HEALTH CHECKS (EPSDT),” 64 This assessment does not include a comprehensive http://www.sos.state.ne.us/business/regsearch/R review of all food tax policies in all states. Some ules/Health_and_Human_Services_System/Title- states with a general food tax that covers “junk 471/Chapter-33.pdf. food” may not be included in this evaluation. 82 Ibid. 65 Center for Science in the Public Interest, “CSPI to 83 Arizona Health Care Cost Containment System, Urge Taxes on Junk Foods to Fund Health Division of Health Care Management, Campaigns,” 25 May 25 2000, “Arizona’s School Readiness Action Plan: The http://www.cspinet.org/new/tax_junkfood.html AHCCCS Report Card on Children’s Preventive (13 September 2004). Health Initiatives,” May 2005, http://www.ahc- 66 “Fat Tax Could Save Lives,” BBC News, 28 ccs.state.az.us/Studies/SchoolReadinessReport/ January 2000, http://news.bbc.co.uk/1/hi/ SRBReportCard5-05.pdf. health/620844.stm (13 September 2004). 84 K.M. Elliott, “AHCCCS Childhood Obesity 67 National Restaurant Association, “House Vote to Medical Guidelines,” http://www.azdhs.gov/phs/ Prevent Frivolous Lawsuits Against Restaurants, oncdps/opp/pdf/childhood_obesity_medical_gu Food Manufacturers: Just Plain Common idelines.pdf. Sense,” Press Release, 10 March 2004, 85 Ibid. http://www.restaurant.org/pressroom/print/in 108 86 Ibid. dex.cfm?ID=833 (15 September 2004). 87 Ibid. 108 S. Rosenbaum, S. Wilensky, M. Cox, and D.B. 88 S. Rosenbaum, S. Wilensky, M. Cox, and D.B. Wright, Reducing Obesity Risks During Childhood: Wright, Reducing Obesity Risks During Childhood: The Role of Public and Private Health Insurance The Role of Public and Private Health Insurance (Washington, D.C.: The George Washington (Washington, D.C.: The George Washington University Medical Center, School of Public University Medical Center, School of Public Health & Health Services, Department of Health & Health Services, Department of Health Policy, July 2005). Health Policy, July 2005). 109 K. Kompas, “Medicare Coverage Can Help 89 Ibid. Obesity, Experts Say,” St. Cloud Times, 30 July 2004. 90 J. Appleby, “Medicare to Cover Surgery to Treat 110 Healthology, “Weight-Loss Surgery Options: Obesity,” USA Today, 22 February 2006. Affording Weight-Loss Surgery,” http://weight- losssurgeryoptions.com/weightlosssurgeryop- 91 J. Bell, “Riverside Adding Bariatric Surgery as tions/article-surgery_afford.asp (3 May 2007). Medicare OKs Reimbursement,” Business First of Columbus, 13 October 2006. 111 Ibid. 92 A. Fine, “Medicare Considers Shift in Coverage 112 “Anti-Obesity Surgery Coverage May Yield on Obesity,” Managed Care Quarterly 13, no. 2 Huge Medicare Savings,” Inside CMS 9, no. 5 (9 (2005): 34-35. March 2006). 93 D.J. Tuttle, “Reluctant insurers shy away from 113 J. Appleby, “Medicare to Cover Surgery to weight-loss surgery coverage,” San Antonio Treat Obesity,” USA Today, 22 February 2006. Business Journal, 27 November 2006. 114 Ibid. 94 Ibid. 115 U.S. Department of Agriculture, Farm Bill:Title IV 95 J. Krasner, “Insurer Aids Obesity-Care Nutrition. 2007. http://www.fns.usda.gov/cga/ Hospitals,” Boston Globe, 2 March 2007. 2007_Farm_Bill/07title4.doc (31 July 2007). 96 J. Krasner, “Insurer Aids Obesity-Care 116 Ibid. Hospitals,” Boston Globe, 2 March 2007. 117 A. Sisson, “Fruit and Vegetable Consumption by 97 J. Krasner, “Insurer Aids Obesity-Care Low-Income Americans,” Nutrition Noteworthy 5, Hospitals,” Boston Globe, 2 March 2007. no. 1 (2002), http://repositories.cdlib.org/cgi/ viewcontent.cgi?article=1040&context=uclabi- 98 J. Krasner, “State Blasts Tufts Plan for Obesity olchem/nutritionnoteworthy. Treatment: Agency Says Policy May Hurt Patients,” Boston Globe, 24 February 2007. 118 The Urban Grocery Store Gap (Storrs, Connecticut: Food Marketing Policy Center, University of 99 Information provided to TFAH by GSK. Connecticut, 1995); P.M. Morris, Higher Prices, 100 Associated Press, “Limiting junk food ads aimed at Fewer Choices: Shopping for Food in Rural America kids,” 18 July 2007, http://www.azcentral.com/ (Washington, D.C.: Public Voice for Food and business/articles/0718biz-nokidads18-ON.html. Health Policy, 1990). 101 PepsiCo, “PepsiCo Strengthens Marketing 119 J. Putnam, J. Allshouse, and L.S. Kantor, “U.S. Practices to Children,” 18 July 2007, Per Capita Food Supply Trends: More Calories, http://www.prnewswire.com/cgi- Refined Carbohydrates, and Fats,” FoodReview 25, bin/stories.pl?ACCT=104&STORY=/www/stor no. 3 (Winter 2002); and Institute for Agricul- y/07-18-2007/0004628074&EDATE=. ture and Trade Policy, “Food Without Thought: How U.S. Farm Policy Contributes to Obesity,” 102 S. Basu, “Military Not Immune from Obesity November 2006, http://www.iatp.org/ iatp/fact- ‘Epidemic,’” U.S. Medicine Information sheets.cfm?accountID=258&refID=89968. Center, 25 March 2004, http://www.usmedi- cine.com/dailyNews.cfm?dailyID=187. 120 J.C. Buzby, H.F. Wells, and G. Vocke, Possible Impli- cations for U.S. Agriculture From Adoption of Select 103 H. El Nasser, “Recruits’ fitness weighs on military,” Dietary Guidelines, Report #31 (Washington, DC: USA Today, 29 March 2007. U.S. Department of Agriculture, November 2006). 104 U.S. Veterans Administration, National Center 121 Ibid. for Health Promotion and Disease Prevention, “Managing Overweight/Obesity for Veterans 122 U.S. Department of Agriculture, Economic Everywhere,” 16 August 2004. Research Service, “The Food Assistance Landscape,” Economic Information Bulletin 6- 105 U.S. Department of Agriculture, Memorandum 2, March 2006. of Understanding to Promote Public Health and Recreation (Washington, DC: U.S. Department 123 U.S. Department of Agriculture, 2007 Farm Bill of Agriculture, 19 June 2002). Proposal (Washington, DC: U.S. Department of Agriculture, 2007). 106 Georgia Institute of Technology, Georgia Tech Research Institute, ATAS Lab, “SMARTRAQ,” 124 G. Lucier, S. Pollack, M. Ali, and A. Perez, http://www.smartraq.net (9 September 2004). Fruit and Vegetable Backgrounder, Report #VGS- 313-01 (Washington, DC: U.S. Department of 107 “Medicare Expands Coverage for Lifesaving Agriculture, April 2006). Obesity Surgery; Private Insurers Expected to Follow Suit,” PR Newswire US, 22 February 2006. 109 125 S.J. Hedges, “To subsidize actual food; Corn. 139 U.S. Centers for Disease Control and Cotton. Rice. Soybeans. Wheat. This year’s Prevention, “Our Mission: Four Strategies to farm bill may focus less on these staples in an Promote National School Health,” 8 June 2007, effort...” Chicago Tribune, 20 March 2007. http://www.cdc.gov/HealthyYouth/about/mis- 126 M. Paggi, Specialty Crops and the 2007 Farm Bill sion.htm (4 July 2007). (Washington, DC: American Enterprise 140 Ibid. Institute, 2007). 141 U.S. Centers for Disease Control and 127 J. Putnam, J. Allshouse, and L.S. Kantor, “U.S. Prevention, Steps to a HealthierUS Program: Per Capita Food Supply Trends: More Calories, Preventing Chronic Diseases Through Local Refined Carbohydrates, and Fats,” FoodReview Community Action (Atlanta, GA: Centers for 25, no. 3 (Winter 2002). Disease Control and Prevention, April 2007). 128 J. Buzby, H. Farah, and G. Vocke, “Will 2005 142 The U.S. Centers for Disease Control and Be the Year of the Whole Grain?” Amber Waves Prevention did not provide the information (June 2005): 12-17. requested by TFAH for the amounts on a dis- 129 L. Mancino and J. Buzby, “Americans’ Whole- aggregated basis. Grain Consumption Below Guidelines,” Amber 143 National Insitutes of Health, “NIH Releases Waves (April 2005): 5. Research Strategy to Fight Obesity Epidemic,” Press 130 S. Kahan, “The USDA’s Unhealthful Budget,” Release, 24 August 2004, http://www.nih.gov/ Baltimore Sun, 1 May 2007. news/pr/aug2004/niddk-24.htm. 131 U.S. Department of Agriculture, Economic 144 FY 2006 funding information given directly to Research Service, “Soybeans and Oil Crops: TFAH from the National Institutes of Health, Background,” 25 April 2005, June 2007. http://www.ers.usda.gov/Briefing/SoybeansOilc 145 National Institutes of Health, “Prevention and rops/background.htm (4 July 2007). Treatment of Childhood Obesity in Primary 132 S. Kahan, “The USDA’s Unhealthful Budget,” Care Settings,” RFA #: RFA-HD-04-020, Baltimore Sun, 1 May 2007. http://grants.nih.gov/grants/guide/rfa- files/RFA-HD-04-020.html (9 July 2007). 133 J. Putnam, J. Allshouse, and L.S. Kantor, “U.S. Per Capita Food Supply Trends: More Calories, 146 National Institutes of Health, “Obesity and the Refined Carbohydrates, and Fats,” FoodReview Built Environment,” RFA#: RFA-ES-04-003, 25, no. 3 (Winter 2002). http://grants.nih.gov/grants/guide/rfa- files/RFA-ES-04-003.html (9 July 2007). 134 National Coalition for Promoting Physical Activity. Letter to Congress concerning No 147 National Institutes of Health, “Overweight and Child Left Behind Legislation. 12 June 2007. Obesity Control at Worksites,” RFA#: RFA-HL- 04-006, http://grants.nih.gov/grants/guide/rfa- 135 J.B. Grissom, “Physical fitness and academic files/RFA-HL-04-006.html (9 July 2007). achievement,” Journal of Exercise Physiology online 8 (2005): 11-25; C.W. Symons and B. Cinelli, 148 Information given directly to TFAH from the “Bridging student health risks and academic National Institutes of Health, “Examples of NIH- achievement through comprehensive school Supported Obesity Research Efforts,” June 2007. health programs,” Journal of School Health 67, no. 149 Ibid. 6 (1997); L.J. Kolbe et al., “Appropriate 150 Ibid. Functions of Health Education in Schools: Improving Health and Cognitive Performance.” 151 Ibid. In N.A. Krasnegor, J.D. Arasteh, and M.F. 152 T.A. Wadden, K.D. Brownell, and G.D. Foster, Cataldo (Eds.), Child Health Behavior: A “Obesity: Responding to the Global Epidemic,” Behavioral Pediatrics Perspective (New York: John Presentation, 8 January 2004. From an article Wiley & Sons, 1986); and California Department originally published in Journal of Consulting and of Education, “The Relationship Between Clinical Psychology 70, no. 3 (June 2002): 510-525. Physical Fitness and Academic Achievement,” 153 S.N. Blair and M.J. LaMonte, “Commentary: 2001 PFT/SAT-9 Study, Sacramento, CA, 2002. Current Perspectives on Obesity and Health: 136 S. Barlow and W. Dietz, “Obesity Evaluation Black and White, or Shades of Grey?” International and Treatment: Expert Committee Journal of Epidemiology 35 (2006): 69-72. Recommendations,” Pediatrics 102, no. 3 154 U.S. Centers for Disease Control and Prevention, (September 1998). Behavioral Risk Factor Surveillance System Survey 137 Note: Some U.S. Centers for Disease Control Data (Atlanta, GA: U.S. Department of Health and Prevention suggest the use of the term and Human Services, Centers for Disease “cooperative agreement” and others suggest Control and Prevention, 2006). the use of the term “grant” for these programs. 155 U.S. Centers for Disease Control and Prevention, 138 U.S. Centers for Disease Control and Behavioral Risk Factor Surveillance System Survey Prevention, “Overweight and Obesity: State- Data (Atlanta, GA: U.S. Department of Health Based Programs,” 22 May 2007, and Human Services, Centers for Disease http://www.cdc.gov/nccdphp/dnpa/obesity/s Control and Prevention, 2005). tate_programs/index.htm (4 July 2007). 110 156 S.N. Blair, “The Importance of Fitness in 173 Ibid. Children and Adults,” Presentation at the 174 R.S. Paffenbarger Jr., R.T. Hyde, A.L. Wing, I.-M. Thirteen Anniversary Annual Meeting, Lee, D.L. Jung and J.B. Kampert, “The association Institute of Medicine, 16 October 2000. of changes in physical-activity level and other life- 157 U.S. Department of Health and Human Services, style characteristics with mortality among men,” Public Health Service, Centers for Disease Control New England Journal of Medicine 328, no. 8 (1993): and Prevention, National Center for Chronic 538-545. Disease Prevention and Health Promotion, 175 C.D. Lee, S.N. Blair, and A.S. Jackson, “Cardio- Division of Nutrition and Physical Activity, respiratory fitness, body composition, and all- Promoting Physical Activity: A Guide for Community cause and cardiovascular disease mortality in Action (Champaign, IL: Human Kinetics, 1999). men,” American Journal of Clinical Nutrition 69, 158 U.S. Centers for Disease Control and Prevention, no. 3 (1999): 373-380. “Youth Risk Behavior Surveillance - United States 176 J. Lynch, S.P. Helmrich, T.A. Lakka, G.A. Kaplan, 2005,” MMWR Surveillance Summaries 55, no. SS-5 R.D. Cohen, R. Salonen and J.T. Salonen, (9 June 2006). “Moderately intense physical activities and high 159 Ibid. levels of cardiorespiratory fitness reduce the risk 160 M.J. McGinnis, Obesity: An American Public of non-insulin-dependent diabetes mellitus in Health Epidemic, Strategies to Better Understand It middle-aged men,” Archives of Internal Medicine and Change America’s Behavior (Washington, 156, no. 12 (1996): 1307-1314. DC: National Institute for Health Care 177 G. Hu, J. Lindstrom, T.T. Valle, J.G. Eriksson, P. Management, December 2004). Jousilahti, K. Silventoinen, Q. Qiao and J. 161 For more details on the trends, see Trust for Tuomilehto, “Physical Activity, Body Mass Index, America’s Health F as in Fat: How Obesity and Risk of Type 2 Diabetes in Patients with Policies Are Failing in America - 2005, p. 94. Normal or Impaired Glucose Regulation,” Archives of Internal Medicine 164, no. 8 (2004): 892-896. 162 J. Putnam, J. Allshouse, and L.S. Kantor, “US Per Capita Food Supply Trends,” Food Review 25, no. 178 C.Y. Jeon, R.P. Lokken, F.B. Hu and R.M. Van 3 (Winter 2002), http://www.ers.usda.gov/publi- Dam, “Physical activity of moderate intensity cations/FoodReview/DEC2002/frvol25i3a.pdf and risk of type 2 diabetes: A systematic (June 2005). review,” Diabetes Care 30, no. 3 (2007): 744-752. 163 “Trends in Intake of Energy and Macronutrients - 179 T.Y. Li, J.S. Rana, J.E. Manson, W.C. Willett, M.J. United States, 1971-2000,” MMWR 53, no. 4 Stampfer, G.A. Colditz, K.M. Rexrode and F.B. (2004): 80-82. Hu, “Obesity as compared with physical activity in predicting risk of coronary heart disease in 164 R.R. Briefel and C.L. Johnson, “Secular Trends women,” Circulation 113, no. 4 (2006): 499-506. in Dietary Intake in the United States,” Annual Review of Nutrition 24 (2004): 401-431. 180 J.E. Manson, F.B. Hu, J.W. Rich-Edwards, G.A. Colditz, M.J. Stampfer, W.C. Willett, F.E. 165 S.J. Nielsen and B.M. Popkin, “Patterns and Trends Speizer and C.H. Hennekens, “A prospective in Food Portion Sizes, 1977-1998,” Journal of the study of walking as compared with vigorous American Medical Association 289 (2003): 450-3. exercise in the prevention of coronary heart 166 J. Putnam, J. Allshouse, and L.S. Kantor, “US Per disease in women,” New England Journal of Capita Food Supply Trends,” Food Review 25, no. Medicine 341, no. 9 (1999): 650-658. 3 (Winter 2002), http://www.ers.usda.gov/publi- 181 J.E. Manson, P. Greenland, A.Z. LaCroix, M.L. cations/FoodReview/DEC2002/frvol25i3a.pdf Stefanick, C.P. Mouton, A. Oberman, M.G. (June 2005). Perri, D.S. Sheps, M.B. Pettinger and D.S. 167 Ibid. Siscovick, “Walking compared with vigorous exercise for the prevention of cardiovascular 168 Ibid. events in women,” New England Journal of 169 Ibid. Medicine 347, no. 10 (2002): 716-725. 170 Ibid. 182 B. Bulwer, “Sedentary Lifestyles, Physical 171 L. Cleveland, “National Food Consumption Survey, Activity, and Cardiovascular Disease: From 1977-78,” U.S. Department of Agriculture, Research to Practice,” Critical Pathways in Economic Research Service; and U.S. Centers for Cardiology 3, no. 4 (December 2004): 184. Disease Control and Prevention, “What We Eat in 183 G. Hu et al., “Physical activity, cardiovascular risk America,” National Health and Nutrition factors, and mortality among finish adults with Examination Survey, 2001-02, http://www.cdc.gov/ diabetes,” Diabetes Care 28, no. 4 (2005): 799-805. nchs/nhanes.htm (15 June 2005). 184 Ibid. 172 U.S. Department of Health and Human 185 Ibid. Services, Centers for Disease Control and Prevention, National Center for Chronic 186 H.E. Resnick et al., “Achievement of American Disease Prevention and Health Promotion, Diabetes Association clinical practice recom- Physical Activity and Health: A Report of the mendations among U.S. adults with diabetes, Surgeon General (Atlanta, GA: U.S. Centers for 1999-2002: The National Health and Nutrition Disease Control and Prevention, 1996). Examination Survey,” Diabetes Care 29, no. 3 (2006): 531-537. 111 187 S.S. Gidding et al., “Higher self-reported physical 200 M. Murphy et al., “Accumulating brisk walking activity is associated with lower systolic blood for fitness, cardiovascular risk, and psychologi- pressure: The Dietary Intervention Study in cal health,” Medicine and Science in Sports and Childhood (DISC),” Pediatrics 118, no. 6 (2006): Exercise 34, no. 9 (2002): 1468-1474. 2388-2393. 201 D.J. Macfarlane et al., “Very short intermittent vs 188 S. Brage et al., “Features of the metabolic syn- continuous bouts of activity in sedentary adults,” drome are associated with objectively measured Preventive Medicine 43, no. 4 (2006): 332-336. physical activity and fitness in Danish children: 202 M. Murphy et al., “Accumulating brisk walking The European Youth Heart Study (EYHS),” for fitness, cardiovascular risk, and psychologi- Diabetes Care 27, no. 9 (2004): 2141-2148. cal health,” Medicine and Science in Sports and 189 W.B. Strong et al., “Evidence based physical Exercise 34, no. 9 (2002): 1468-1474. activity for school-age youth,” Journal of 203 National Institutes of Diabetes and Digestive and Pediatrics 146, no. 6 (2005): 732-737. Kidney Diseases, Weight-control Information 190 R. Kelishadi et al., “Association of physical Network, “Do You Know the Health Risks of activity and the metabolic syndrome in chil- Being Overweight?” November 2004, dren and adolescents: CASPIAN Study,” http://win.niddk.nih.gov/publications/health_r Hormone Research 67, no. 1 (2007): 46-52. isks.htm. 191 G. Imperatore et al., “Physical activity, cardio- 204 C.C. Cowie, K.F. Rust, D.D. Byrd-Hold, M.S. vascular fitness, and insulin sensitivity among Eberhardt, K.M. Flegel, M.M. Engelgau, S.H. U.S. adolescents: The National Health and Saydah, D.E. Williams, L.S. Geiss and E.W. Gregg, Nutrition Examination Survey, 1999-2002,” “Prevalence of Diabetes and Imparted Fasting Diabetes Care 29, no. 7 (2006): 1567-1572. Glucose in Adults in the US Population: NHANES 192 L.B. Andersen et al., “Physical activity and clus- 1999-2002.” Diabetes Care 29 (2006): 1263-8. tered cardiovascular risk in children: a cross- 205 Ibid. sectional study (The European Youth Heart 206 U.S. Centers for Disease Control and Study),” Lancet 368, no. 9532 (2006): 299-304. Prevention, CDC Protecting Health for Life: The 193 National Institutes of Health, “Insulin State of the CDC, Fiscal Year 2004 (Atlanta, GA: Resistance and Pre-Diabetes,” August 2006, U.S. Centers for Disease Control and http://diabetes.niddk.nih.gov/dm/pubs/insul Prevention, March 2005). inresistance/ (2 July 2007). 207 K.M. Venkat Narayan, J.P. Boyle, L.S. Geiss, J.B. 194 U.S. Centers for Disease Control and Saaddine and T.J. Thompson, “Impact of Recent Prevention, “CDC funds registries for child- Increase in Incidence on Future Diabetes hood diabetes,” Press Release, 21 November Burden: United States, 2005-2050,” Diabetes Care 2000, http://www.cdc.gov/od/oc/media/press- 29, no. 9 (September 2006): 2114-2116. rel/r2k1226.htm (2 July 2007). 208 American Diabetes Association, “Total Prevalence 195 R.S. Paffenbarger Jr., R.T. Hyde, A.L. Wing, I.- of Diabetes & Pre-diabetes,” http://diabetes.org/ M. Lee, D.L. Jung and J.B. Kampert, “The asso- diabetes-statistics/prevalence.jsp (10 July 2007). ciation of changes in physical-activity level and 209 Ibid. other lifestyle characteristics with mortality among men,” New England Journal of Medicine 210 Ibid. 328, no. 8 (1993): 538-545. 211 American Heart Association. Heart Disease and 196 J.E. Manson, F.B. Hu, J.W. Rich-Edwards, G.A. Stroke Statistics - 2006 update. Dallas, Texas: Colditz, M.J. Stampfer, W.C. Willett, F.E. American Heart Association; 2006. Speizer and C.H. Hennekens, “A prospective 212 Ibid. study of walking as compared with vigorous 213 National Institutes of Diabetes and Digestive and exercise in the prevention of coronary heart Kidney Diseases, Weight-control Information disease in women,” New England Journal of Network, “Do You Know the Health Risks of Medicine 341, no. 9 (1999): 650-658. Being Overweight?” November 2004, 197 F.B. Hu et al., “Walking compared with vigor- http://win.niddk.nih.gov/publications/ ous physical activity and risk of type 2 diabetes health_risks.htm. in women: A prospective study,” JAMA 282, no. 214 Ibid. 15 (1999): 1433-1439. 215 American Obesity Association, “Health Affects 198 J.E. Manson, F.B. Hu, J.W. Rich-Edwards, G.A. of Obesity,” http://www.obesity.org/subs/fast- Colditz, M.J. Stampfer, W.C. Willett, F.E. facts/Health_Effects.shtml (6 June 2005). Speizer and C.H. Hennekens, “A prospective study of walking as compared with vigorous 216 National Institutes of Diabetes and Digestive exercise in the prevention of coronary heart and Kidney Diseases, Weight-control disease in women,” New England Journal of Information Network, “Do You Know the Medicine 341, no. 9 (1999): 650-658. Health Risks of Being Overweight?” November 2004, http://win.niddk.nih.gov/publica- 199 F.B. Hu et al., “Walking compared with vigorous tions/health_risks.htm. physical activity and risk of type 2 diabetes in women: A prospective study,” JAMA 282, no. 15 (1999): 1433-1439. 112 217 U.S. Centers for Disease Control and Prevention, 233 March of Dimes, “Quick References and Fact “Obesity in the New: Helping Clear the Confusion,” Sheets: Spina Bifida,” April 2006, Power Point Presentation, 25 May 2005. http://www.marchofdimes.com/pnhec/4439_ 218 American Cancer Society, Cancer Facts and Figures 1224.asp (4 July 2007). 2007 (Atlanta, GA: American Cancer Society, 2007). 234 M.L. Watkins et al., “Maternal obesity and risk 219 U.S. Centers for Disease Control and Prevention, for birth defects,” Pediatrics 111, no. 5 (2003): “Obesity in the New: Helping Clear the Confusion,” 1152-1158. Power Point Presentation, 25 May 2005. 235 Medline Plus, “Omphalocele,” August 2006, 220 A.M. Elliott et al., “Weight Change in Adult http://www.nlm.nih.gov/medlineplus/ency/ar Life and Health Outcomes.” Obesity Research 13, ticle/000994.htm (4 July 2007). no. 10 (October 2005). 236 M.L. Watkins et al., “Maternal obesity and risk 221 R.A. Whitmer, E.P. Gunderson et al., “Obesity in for birth defects,” Pediatrics 111, no. 5 (2003): Middle Age and Future Risk of Dementia: a 27 1152-1158. Year Longitudinal Population Based Study,” British 237 Ibid. Medical Journal 330, no. 7504 (April 2005): 1360. 238 J.L. Anderson et al., “Maternal obesity, gestation- 222 W.H. 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Harrell, and R.A. Bell, “Over- 243 D. Gustafson et al., “An 18-year follow-up of over- weight in Children: Definitions, Measurements, weight and risk of Alzheimer disease,” Archives of Confounding Factors, and Health Consequences,” Internal Medicine 163, no. 13 (2003): 1524-1528. Journal of Pediatric Nursing 19 (2004): 376-384. 244 G. Razay et al., “Obesity, Abdominal Obesity and 227 K. Johnson et al., “Recommendations to Alzheimer Disease,” Dementia and Geriatric Cognitive Improve Preconception Health and Health Disease 22 (2006): 173-176; and R. Whitmer et al., Care —- United States: A Report of the “Obesity in Middle Age and Future Risk of CDC/ATSDR Preconception Care Work Group Dementia: a 27-year Longitudinal Population-based and the Select Panel on Preconception Care,” Study,” British Medical Journal 62 (2005): 1556-1560. MMWR 55, no. RR06 (21 April 2006): 1-23. 245 S. Gandy, “The Role of Cerebral Amyloid ß 228 C.A. Slentz et al., “Inactivity, exercise training Accumulation in Common Forms of Alzheimer and detraining, and plasma lipoproteins. STR- Disease,” Journal of Clinical Evaluation 115 RIDE: a randomized, controlled study of exer- (2005):1121-1129. cise intensity and amount,” Journal of Applied Physiology 103 (2007): 432-442. 246 E.C. Gorospe and J.K. Dave, “The risk of dementia with increased body mass index,” Age 229 A.-M. Siega-Riz et al., “The implications of and Ageing 36, no. 1 (2007): 23-29. maternal overweight and obesity on the course of pregnancy and birth outcomes,” Maternal 247 R.A. Whitmer et al., “Obesity in middle age and and Child Health Journal 10 (2006): 153-156. future risk of dementia: A 27 year longitudinal population based study,” BMJ 330, no. 7504 230 C.A. Slentz et al., “Inactivity, exercise training (2005): 1360-1362. and detraining, and plasma lipoproteins. STR- RIDE: a randomized, controlled study of exer- 248 M. Kivipelto et al., “Obesity and vascular risk cise intensity and amount,” Journal of Applied factors at midlife and the risk of dementia and Physiology 103 (2007): 432-442. Alzheimer disease,” Archives of Neurology 62, no. 10 (2005): 1556-1560. 231 K. Johnson et al., “Recommendations to Improve Preconception Health and Health 249 D. DeNoon, “Obesity and Alzheimer’s High Care —- United States: A Report of the Insulin Levels Linked to Alzheimer’s,” WebMD, CDC/ATSDR Preconception Care Work Group 8 August 2005. and the Select Panel on Preconception Care,” 250 Alzheimer’s Association, “What is Alzheimer’s?” MMWR 55, no. RR06 (21 April 2006): 1-23. 2007, http://www.alz.org/alzheimers_disease_ 232 M.L. Watkins et al., “Maternal obesity and risk what_is_alzheimers.asp (4 July 2007). for birth defects,” Pediatrics 111, no. 5 (2003): 251 Ibid. 1152-1158. 113 252 Alzheimer’s Association, Alzheimer’s Disease Facts 268 N.P. Pronk et al., “The Association between Work and Figures, 2007 (Chicago, IL: Alzheimer’s Performance and Physical Activity, Cardiorespir- Association, 2007). atory Fitness, and Obesity,” Journal of Occupational 253 Ibid. and Environmental Medicine 46, no. 1 (2004): 19-25. 254 U.S. Department of Health and Human 269 S.G. Aldana and N.P. Pronk, “Health promotion Services, Prevention Makes Common “Cents” programs, modifiable health risks, and employee (Washington, DC: U.S. Department of Health absenteeism,” Journal of Occupational and and Human Services, September 2003). Environmental Medicine 43, no. 1 (2001): 36-46. 255 L.H. Anderson et al., “Health Care Charges 270 Gordian Health Solutions, Managing the Obesity Associated with Physical Inactivity, Overweight, Problem: A Case Study with Measurable Results and Obesity,” Preventing Chronic Disease 2, no. 4 (Nashville, TN: Gordian Health Solutions, 2007). (October 2005). 271 F. Wang et al., “Relationship of Body Mass Index 256 K.E. Thorpe et al., “The impact of obesity on ris- and Physical Activity to Health Care Costs ing medical spending,” Health Affairs 23 (2004). among Employees,” Journal of Occupational and Environmental Medicine 46, no. 5 (2004): 428-436. 257 G. Wang and W.H. Dietz, “Economic burden of obesity in youths aged 6 to 17 years: 1979- 272 W.N. Burton et al., “The economic costs associ- 1999,” Pediatrics 109, no. 5 (2002). ated with body mass index in the workplace,” Journal of Occupational and Environmental Health 258 J.A. Rhoades, “Overweight and Obese Elderly 40, no. 9 (1998): 786-792. and Near Elderly in the United States, 2002: Estimates for the Noninstitutionalized Population 273 H. Xiang et al., “Obesity and risk of nonfatal Age 55 and Older,” Statistical Brief #68, Agency unintentional injuries,” American Journal of for Healthcare Research and Quality, February Preventive Medicine 29, no. 1 (2005): 41-45. 2005, http://www.meps.ahrq.gov/papers/st68/ 274 T. Ostbye et al., “Obesity and workers’ com- stat68.pdf. pensation: Results from the Duke Health and 259 N.A. Garrett et al., “Physical inactivity: Direct Safety Surveillance System,” Archives of Internal cost to a health plan,” American Journal of Medicine 167, no. 8 (2007): 766-773. Preventive Medicine 27, no. 4 (2004): 304-309. 275 Ibid. 260 G. Wang, M. Pratt, C.A. Macera, Z.J. Zheng and G. 276 B. Tolles, “Obese weigh down U.S. economy,” Heath, “Physical Activity, Cardiovascular Disease, Daily Northwestern, 5 May 2005. and Medical Expenditures in U.S. Adults,” Can J 277 Ibid. Appl Physiol. 29, no. 1 (February 2004): 90-115. 278 R. French, “Losing the battle of the bulge; 261 B. Bulwer, “Sedentary Lifestyles, Physical Unhealthy lifestyles weigh heavily on company’s Activity, and Cardiovascular Disease: From health care costs,” Detroit News, 27 September 2006. Research to Practice,” Critical Pathways in Cardiology 3, no. 4 (December 2004): 184. 279 F. Wang et al., “The relationship between National Heart, Lung and Blood Institute weight 262 R. Colman and S. Walker, “The Cost of Physical guidelines and concurrent medical costs in a Inactivity in British Columbia,” Genuine manufacturing population,” American Journal of Progress Index for Atlanta Canada for the B.C. Health Promotion 17, no. 3 (2003): 183-189. Ministry of Health Planning, November 2004. 280 R. French, “Losing the battle of the bulge; 263 T. Ostbye et al., “Obesity and workers’ com- Unhealthy lifestyles weigh heavily on company’s pensation: Results from the Duke Health and health care costs,” Detroit News, 27 September 2006. Safety Surveillance System,” Archives of Internal Medicine 167, no. 8 (2007): 766-773. 281 L.H. Anderson et al., “Health Care Charges Associated with Physical Inactivity, Overweight, 264 N.A. Garrett et al., “Physical inactivity: Direct and Obesity,” Preventing Chronic Disease 2, no. cost to a health plan,” American Journal of 4 (October 2005). Preventive Medicine 27, no. 4 (2004): 304-309. 282 E.A. Finkelstein et al., “National medical spending 265 T. Ostbye et al., “Obesity and workers’ com- attributable to overweight and obesity: how much, pensation: Results from the Duke Health and and who’s paying?” Health Affairs Suppl. (2003). Safety Surveillance System,” Archives of Internal Medicine 167, no. 8 (2007): 766-773. 283 M.L. Daviglus et al., “Relation of body mass index in young adulthood and middle age to 266 N.P. Pronk et al., “The Association between Medicare expenditures in older age,” JAMA Work Performance and Physical Activity, 292, no. 22 (2004): 2743-2749. Cardiorespiratory Fitness, and Obesity,” Journal of Occupational and Environmental 284 M.A. Raebel et al., “Health services use and Medicine 46, no. 1 (2004): 19-25. health care costs of obese and nonobese indi- viduals,” Archives of Internal Medicine 164, no. 19 267 T. Ostbye et al., “Obesity and workers’ com- (2004): 2135-2140. pensation: Results from the Duke Health and Safety Surveillance System,” Archives of Internal 285 P.A. Eastabrooks and S. Shetterly, “The prevalence Medicine 167, no. 8 (2007): 766-773. of health care use of overweight children in an integrated health care system,” Archives of Pediatrics and Adolescent Medicine 161, no. 3 (2007): 222-227. 114 286 U.S. Department of Health and Human 299 R.R. Pate et al., “Promoting Physical Activity in Services and U.S. Department of Agriculture, Children and Youth: A Leadership Role for “Dietary Guidelines for Americans, 2005,” Schools: A Scientific Statement From the http://www.health.gov/dietaryguidelines/dga2 American Heart Association Council on 005/document/html/chapter4.htm (31 July Nutrition, Physical Activity, and Metabolism 2007). Note: different recommendations appear (Physical Activity Committee) in Collaboration on: U.S. Centers for Disease Control and With the Councils on Cardiovascular Disease Prevention, “Physical Activity for Everyone: in the Young and Cardiovascular Nursing,” Recommendations,” 22 May 2007, Circulation 114 (2006): 1214-1224. http://www.cdc.gov/nccdphp/dnpa/physical/r 300 U.S. Centers for Disease Control and ecommendations/index.htm (2 July 2007). Prevention, “Guidelines for School and 287 W.L. Haskell et al., “Physical Activity and Community Programs to Promote Lifelong Public Health: Updated Recommendation for Physical Activity Among Young People,” Adults From the American College of Sports MMWR 46, no. RR-6 (7 March 1997). Medicine and the American Heart 301 Department of Education, “Carol M. White Association,” Circulation 116 (2007). Physical Education Program (PEP) Grant 288 U.S. Centers for Disease Control and Prevention, Competition: CFDA #84.215F,” “Physical Activity for Everyone: Are there special http://www.ed.gov/programs/whitephysed/2006 recommendations for young people?” 22 May pep.pdf (10 July 2007). 2007, http://www.cdc.gov/nccdphp/dnpa/physi- 302 Ibid. cal/recommendations/young.htm (2 July 2007). 303 National Association for Sport and Physical 289 U.S. Department of Health and Human Services, Education, “Federal Legislation Impacting “HHS Secretary Announces Development of Physical Education,” http://www.aahperd.org/ Physical Activity Guidelines at National naspe/ShapeOfTheNation/template.cfm?tem- Prevention Summit,” Press Release, 26 October plate=appendixB.html (11 July 2007). 2006, http://www.hhs.gov/news/press/ 2006pres/20061026.html. 304 P. Lawler, “Fighting Childhood Obesity,” Testimony before the Committee on House 290 T.A. Wadden, K.D. Brownell and G.D. Foster, Education and Labor Subcommittee on “Obesity: Responding to the Global Epidemic,” Healthy Families and Community, 10 May 2007. Presentation, 8 January 2004. From an article originally published in Journal of Consulting and 305 M. McSherry Breslin, “School tests notion that Clinical Psychology 70, no. 3 (June 2002): 510-525. exercise makes learning easier,” Chicago Tribune, 13 September 2006. 291 Ibid. 306 Institute of Medicine, Preventing Childhood 292 Ibid. Obesity: Health in the Balance (Washington, DC: 293 U.S. Government Accountability Office, National Academies Press, 2005). Childhood Obesity: Most Experts Identified 307 “Kids Living Near School Rarely Walk There: Physical Activity and the Use of Best Practices as Study,” HealthDay, 11 July 2007. Key to Successful Programs, GAO-06-127R (Washington, DC: Government Accountability 308 T.A. Wadden, K.D. Brownell, and G.D. Foster, Office, 2005). “Obesity: Responding to the Global Epidemic,” Presentation, 8 January 2004. From an article 294 Wisconsin Education Association Council, originally published in Journal of Consulting and “Physical Education, Extracurricular Sports Clinical Psychology 70, no. 3 (Jun 2002): 510-525. Suffer under Budget Strains,” 1 June 2004, http://www.weac.org/News/2003- 309 D.J. Aaron et al., “Longitudinal Study of the 04/jun04/phyed.htm (20 September 2004). Number and Choice of Leisure Time Physical Activities from Mid to Late Adolescence,” 295 U.S. Centers for Disease Control and Archives of Pediatrics & Adolescent Medicine 156, Prevention, “Youth Risk Behavior Surveillance no. 11 (November 2002). - United States 2005,” MMWR Surveillance Summaries 55, no. SS-5 (9 June 2006). 310 J. Giammettei et al., “Television Watching and Soft Drink Consumption,” Archives of Pediatric & 296 Ibid. Adolescent Medicine 147, no. 9 (September 2003). 297 National Center for Chronic Disease Prevention 311 J.L. Wiecha et al., “When Children Eat What and Health Promotion, Centers for Disease They Watch,” Archives of Pediatrics & Adolescent Control and Prevention, “Healthy Youth! Youth Medicine 160, no. 4 (April 2006). Online: Comprehensive Results,” 30 March 2007, http://apps.nccd.cdc.gov/yrbss/ 312 Ibid. SelectLocyear.asp?cat=6&Quest=Q80. 313 R.V. Luepker et al., “Outcomes of a Field Trial 298 National Association for Sport & Physical to Improve Children’s Dietary Patters and Education, http://www.aahperd.org/naspe/ Physical Activity. The Child and Adolescent template.cfm?template+difference.html. Trial for Cardiovascular Health, CATCH Collaborative Group.” Journal of the American Medical Association 275, no. 10 (March 1996). 115 314 P.R. Nader, E.J. Stone, L.A. Lytle, C.L. Perry, 330 C.D. Economos et al., “A Community S.K. Osganian, S. Kelder, L.S. Webber, J.P. Elder, Intervention Reduces BMI z-score in Children: D. Montgomery, H.A. Feldman, M. Wu, C. Shape Up Somerville First Year Results,” Johnson, G.S. Parcel and R.V. Luepker, “Three- Obesity 15, no. 5 (May 2007): 1325-1336. year maintenance of improved diet and physical 331 YMCA of the USA, “About the YMCA: YMCA activity. The CATCH cohort,” Archives of Pediatric Activate America,” http://www.ymca.net/acti- and Adolescent Medicine 153 (1999): 695-704. vateamerica/ (10 July 2007). 315 J.F. Sallis et al., “The Association of School 332 Ibid. Environments with Youth Physical Activity,” American Journal of Public Health 91, no. 4 (2001). 333 YMCA of the USA, “YMCA leads the way to healthier communities,” http://www.ymca.net/ 316 A.L. Carrel et al., “Improvement of Fitness, activateamerica/activate_america_leadership.ht Body Composition, and Insulin Sensitivity in ml (10 July 2007). Overweight Children in a School-Based Exercise Program,” Archives of Pediatrics and 334 Ibid. Adolescent Medicine 159 (October 2005). 335 YMCA of the USA, “YMCA Activate America: 317 R.R. Pate et al., “Promotion of Physical Activity Pioneering Healthier Communities Sites,” Among High-School Girls: A Randomized http://www.ymca.net/activateamerica/pio- Controlled Trial,” American Journal of Public neering_healthy_communities_sites.html (10 Health 95, no. 9 (September 2005). July 2007). 318 Stanford University School of Medicine, 336 YMCA of the USA, “YMCA leads the way to “Building ‘Generation Play’: Addressing the healthier communities,” http://www.ymca.net/ Crisis of Inactivity Among America’s Children,” activateamerica/activate_america_leadership.ht February 2007, http://www.playeveryday.org/ ml (10 July 2007). Stanford%20Report.pdf. 337 “YMCA Initiative Fuels Community-Based 319 “Harkin Introduces New Bill to Promote Approach to Combat Obesity and Chronic Physical Activity for Children,” Press Release, Disease,” Medical News Today, 26 September 15 February 2007, http://harkin.senate.gov 2006, http://www.medicalnewstoday.com/med- /press/print-release.cfm?id=269401. icalnews.php?newsid=52681 (10 July 2007). 320 Ibid. 338 YMCA Activate America, “Lessons Learned: Pioneering Healthier Communities,” 2006, 321 U.S. Department of Health and Human http://www.ymca.net/downloads/aa_phc_les- Services, Public Health Service, Centers for sons_learned_report.pdf (10 July 2007). Disease Control and Prevention, National Center for Chronic Disease Prevention and 339 Ibid. Health Promotion, Division of Nutrition and 340 National Recraetion and Park Association. Physical Activity, Promoting Physical Activity: A www.nrpa.org/health. (31 July 2007). Guide for Community Action (Champaign, IL: 341 U.S. Department of Health and Human Human Kinetics, 1999.) Services, Centers for Disease Control and 322 INShape Indiana, “INSight Youth Corps,” Prevention, National Center for Chronic http://www.in.gov/inshape/insight/ (9 July 2007). Disease Prevention and Health Promotion, 323 Inside INdiana Business, “State Challenge: Get Physical Activity and Health: A Report of the INShape Indiana.” 13 July 2005, Surgeon General (Atlanta, GA: U.S. Centers for http://www.insideindianabusiness.com/newsit Disease Control and Prevention, 1996). em.asp?ID=14404 (9 July 2007). 342 D.A. Galuska et al., “Are health care profes- 324 Information provided to TFAH by the North sionals advising obese patients to lose weight?” Carolina Department of Health and Human JAMA 282, no. 16 (1999): 1576-1578. Services. 343 C.C. Wee et al., “Physician counseling about 325 U.S. Centers for Disease Control and Prevention, exercise,” JAMA 282, no. 16 (1999): 1583-1588. “Washington State: Building a Healthy, Active 344 NHLBI Working Group on Competencies for Community,” 2006, http://www.cdc.gov/ nccd- Overweight and Obesity Identification, Prevention, php/dnpa/obesity/state_programs/state_sto- and Treatment (Bethesda, MD: National Heart ries/wa_community_2006.pdf (4 July 2007). Lung and Blood Institute, National Institutes of 326 Ibid. Health, 2005), http://www.nhlbi.nih.gov/meet- ings/workshops/overweight/report.htm. 327 Ibid. 345 “Blue Cross of California Launches BMI 328 C.D. Economos et al., “A Community Training and Promotion Program to Make Intervention Reduces BMI z-score in Children: Childhood Obesity Screening a Statewide Shape Up Somerville First Year Results,” Standard,” PR Newswire US, 21 June 2006. Obesity 15, no. 5 (May 2007): 1325-1336. 346 M.T. Story et al., “Management of child and 329 T. Parker-Pope, “Snack Attack: As Child adolescent obesity: Attitudes, barriers, skills, Obesity Surges, One Town Finds Way to Slim,” and training needs among health care profes- Wall Street Journal, 10 May 2007. sionals,” Pediatrics 110, no. 1 (2002): 210-214. 116 347 “Obesity Research; Physicians are nervous to 366 “Minnesota Leaders Set Goal to Make talk to parents about children’s weight issues,” Minnesota the Fittest State in the Nation; Law & Healthy Weekly, 15 July 2006. Statewide Leadership Initiative Designed to 348 R.J. Moody, “Kaiser turns alarm into action in Increase Physical Activity and Healthy Eating,” fight against obesity,” Portland Business Journal, PR Newswire US, 25 January 2007. 25 June 2004. 367 J. Forster, “Working Up a Sweat at Work: Blue 349 M.T. Story et al., “Management of child and Cross to Select Up to 20 Companies a Year for adolescent obesity: Attitudes, barriers, skills, Initiative to Improve Health of Employees,” and training needs among health care profes- Pioneer Press, 20 March 2007. sionals,” Pediatrics 110, no. 1 (2002): 210-214. 368 Ibid. 350 S. Caprio, “Treating Child Obesity and 369 M.P. McQueen, “Wellness Policies Reach Out Associated Medial Conditions,” The Future of to the Healthy,” Wall Street Journal, 28 March Children 16, no. 1 (Spring 2006). 2007. 351 American Academy of Pediatrics, Council on 370 Ibid. Sports Medicine and Fitness and Council on 371 Ibid. School Health, “Active Healthy Living: Prevention of Childhood Obesity Through 372 J.F. Sallis and K. Glanz, “The Role of the Built Increased Physical Activity,” Pediatrics 117 (2006). Environment in Physical Activity, Eating, and Obesity in Childhood,” The Future of Children: 352 Ibid. Childhood Obesity 16 (2006): 89-108. 353 “Blue Cross of California Launches BMI 373 L.D. Frank and G. Pivo, “Impact of Mixed Use Training and Promotion Program to Make and Density on Utilization of Three Modes of Childhood Obesity Screening a Statewide Travel: Single-Occupant Vehicle, Transit, and Standard,” PR Newswire US, 21 June 2006. Walking,” Transportation Research Record 1466 354 Association for Community Health (1994): 44-52. Improvement, “Youth Obesity Learning 374 R. Ewing, T. Schmid, R. Killingsworth, A. Zlot Collaborative,” 2007, http://www.communi- and S. Raudenbush, “Relationship between tyhlth.org/communityhlth/projects/youthobe- urban sprawl and physical activity, obesity, and sity/obesityhome.html#purpose. morbidity,” American Journal of Health Promotion 355 Ibid. 18 (2003): 47-57. 356 M.P. McQueen, “Wellness Policies Reach Out to 375 B. Salens, J. Sallis, J. Black and D. Chen, the Healthy,” Wall Street Journal, 28 March 2007. “Neighborhood-based differences in physical 357 Ibid. activity: an environment scale evaluation,” American Journal of Public Health 93 (2003): 358 A. Joyce, “A Prescription for Workers’ Health: 1552-1558. Employers Open In-House Clinics to Trim Costs and Boost Preventive Care,” Washington Post, 9 376 L. Frank, M. Andresen and T. Schmid, October 2006. “Obesity relationships with community design, physical activity, and time spent in cars,” 359 R.Z. Goetzel, T.R. Juday and R.J. Ozminkowski, American Journal of Preventive Medicine (2004), “What’s the ROI? A Systematic Review of Return- doi:10.1016/j.amepre.2004.04.011 On-Investment Studies of Corporate Health and Productivity Management Initiatives,” AWHP’s 377 Surface Transportation Policy Partnership and Worksite Health (Summer 1999): 12-21. Belden Russonello & Stewart, “Americans’ Attitudes Toward Walking and Creating More 360 E.A. McGlynn et al, “The Business Case for a Walkable Communities,” April 2003, Corporate Wellness Program: A Case Study of http://www.transact.org/library/reports_html General Motors and the United Auto Workers,” /pedpoll/pedpoll.asp (7 July 2005). Commonwealth Fund Field Report (April 2003). 378 Ibid. 361 Wharton School of the University of Pennsylvania, “Efforts Are Growing to Trim the 379 U.S. Government Accountability Office, Fat from Employees —- and Employers’ Health Childhood Obesity: Factors Affecting Physical Care Costs,” Knowledge@Wharton, 1 November Activity, GAO-07-260R (Washington, DC: U.S. 2006, http://knowledge.wharton.upenn.edu/. Government Accoutability Office, 2006); and California Department of Education, “The 362 Ibid. Relationship Between Physical Fitness and 363 K. Archer, “Firm’s wellness program curbing Academic Achievement,” 2001 PFT/SAT-9 medical costs: The Nordam Group has saved Study, Sacramento, CA., 2002 $454,000 in a year, and the CEO says employ- 380 R.C. Brownson, T.K. Boehmer and D.A. Luke, ees are healthier and more productive,” Tulsa “Declining Rates of Physical Activity in the World, 6 April 2007. United States: What Are the Contributors?” 364 Ibid. Annual Review of Public Health 26 (2005): 421-43. 365 Ibid. 117 381 This analysis examines an entire population as 385 Figure reflects combined number of respon- the unit of study. Although important for dents indicating that government should have building a scientific base, such studies cannot primary responsibility for addressing obesity determine causality without greater resolution. and those responding that a combination of 382 L.M. Powell, S. Slater and F.J. Chaloupka, “The government and individuals should have pri- Relationship Between Community Physical mary responsibility for addressing obesity in Activity Settings and Race, Ethnicity and Question 4, PLUS those who indicated that Socioeconomic Status,” Evidence-Based Preventive individuals should have primary responsibility Medicine 1, no. 2 (June 2004): 135-144. for addressing obesity but also expressed a desire to see government have some role in 383 “Instructions for Using ENACT,” addressing obesity in Question 5 of the survey. http://www.preventioninstitute.org/sa/enact/ about/enact_instructions.html (11 July 2007). 387 STATA Version 9.0 384 “About ENACT,” http://www.preventioninsti- 388 In all cases, observations with missing values tute.org/sa/enact/members/index.php (11 accounted for less than 5 percent of the total July 2007). number of observations. 118 1707 H Street, NW, 7th Floor Washington, DC 20006 (t) 202-223-9870 (f) 202-223-9871