F as in Fat: ISSUE REPORT 2008 HOW OBESITY POLICIES ARE FAILING IN AMERICA AUGUST 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. TRUST FOR AMERICA’S HEALTH IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES BY PROTECTING THE HEALTH OF EVERY COMMUNITY AND WORKING TO MAKE DISEASE PREVENTION A NATIONAL PRIORITY. The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need-the Foundation expects to make a difference in our lifetime. For more information, visit www.rwjf.org. TFAH BOARD OF DIRECTORS REPORT AUTHORS Lowell Weicker, Jr. Jeffrey Levi, PhD. President Executive Director Former 3-term U.S. Senator and Governor of Connecticut Trust for America’s Health and Cynthia M. Harris, PhD, DABT Associate Professor in the Department of Health Policy Vice President The George Washington University School of Public Director and Associate Professor Health and Health Services Institute of Public Health, Florida A & M University Serena Vinter, MHS Margaret A. Hamburg, MD Lead Author and Senior Research Associate Secretary Trust for America’s Health Senior Scientist Nuclear Threat Initiative (NTI) Rebecca St. Laurent, JD Health Policy Research Assistant Patricia Baumann, MS, JD Trust for America’s Health Treasurer President and CEO Laura M. Segal, MA Bauman Foundation Director of Public Affairs Trust for America’s Health Gail Christopher, DN Vice President for Health WK Kellogg Foundation PEER REVIEWERS TFAH thanks the reviewers for their time, expertise, and insights. John W. Everets The opinions expressed in this report do not necessarily represent David Fleming, MD the views of these individuals or their organizations. Director of Public Health Marcus Plescia, M.D. Seattle King County, Washington Chief, Chronic Disease and Injury Section Robert T. Harris, MD North Carolina Division of Public Health Former Chief Medical Officer and Senior Vice President for Healthcare David P. Hoffman, M.Ed. BlueCross BlueShield of North Carolina Director, Bureau of Chronic Disease Services Alonzo Plough, MA, MPH, PhD New York State Department of Health Vice President of Program, Planning and Evaluation Michael Eriksen, Sc.D. The California Endowment Director and Professor Theodore Spencer Institute of Public Health, Georgia State University Project Manager Natural Resources Defense Council TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 SECTION 1: Obesity Rates and Related Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 A. Adult Obesity and Overweight Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 B. Childhood and Youth Obesity and Overweight Rates . . . . . . . . . . . . . . . . . . .14 C. Physical Inactivity in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 D. Diabetes and Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 E. Obesity and Poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 SECTION 2: Fast Facts About Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 A. What’s Behind the Obesity Epidemic? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 B. Obesity’s Impact on Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 C. Obesity and Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 D. Weight Bias and Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 E. Nutrition: The Other Side of the Energy Balance . . . . . . . . . . . . . . . . . . . . . .30 F. Economic Costs of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 G. The High Price of Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 SECTION 3: State Responsibilities and Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 A. State Obesity Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 B. Survey of Chronic Disease Directors and Directors of Health Promotion and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 C. State Obesity-Related Legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 D. Qualitative Evaluation of State Obesity-Related Legislation . . . . . . . . . . . . . . .56 SECTION 4: Federal Responsibilities and Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 A. Overhaul of the WIC Food Packages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 B. 2008 Farm Bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 C. Reauthorization of the Child Nutrition and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Act . . . . . . . . . .74 D. Reauthorization of No Child Left Behind . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 E. Reauthorization of the State Children’s Health Insurance Program (SCHIP) Act . .76 F. Reauthorization of the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU) . . . . . . . . . . . . . . . . . . . . . . . .77 G. Other Obesity Related Legislation Before Congress . . . . . . . . . . . . . . . . . . . .77 H. Funding For CDC Obesity Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 SECTION 5: A National Strategy to Combat Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 A. Federal Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 B. State Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 C. Local Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 D. Community and Faith-Based Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . .99 E. Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 F. Families and Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 G. Employers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104 H. Insurance Companies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 I. Food and Beverage Industries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107 J. Agribusiness and Farmers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 K. Role for Increased Research and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . .110 L. Special Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Appendix A: Methodology for Obesity and Other Rates Using BRFSS . . . . . . . . . . . . . . . .116 Appendix B: Methodology for State Obesity Plan Review . . . . . . . . . . . . . . . . . . . . . . . . . . . .118 Appendix C: Overview of Federal Programs That Impact Obesity . . . . . . . . . . . . . . . . . . . .119 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128 3 Introduction O besity is one of the most serious health problems in the United States today. Adult obesity rates have doubled since 1980, from 15 percent to 30 percent.1 Two-thirds of adults are now either overweight or obese.2 Childhood obesity rates have nearly tripled since 1980, from 6.5 per- cent to 16.3 percent.3,4 Additionally, the obesity epidemic is taking a toll on the U.S. economy by adding billions of additional dollars in health care costs and hurting our country’s ability to compete in the global economy. It is clear that obesity is impacting the entire country. Rising obesity rates have significant health I Obese children and teenagers are devel- “The report shows the serious consequences: oping diseases that were formerly only impact that the obesity crisis seen in adults. For instance, approxi- is having on our country’s I Adult rates for type 2 diabetes have grown mately 176,500 individuals under the age from 5.2 percent in 1980 to more than 8 health and economic of 20 have type 2 diabetes, and 2 million percent now.5 Approximately 20 million well-being,” said former adolescents aged 12-19 have pre-dia- Americans have type 2 diabetes, and President Bill Clinton, who betes.12 Obese and overweight children another 54 million more have pre-dia- are more likely to become overweight co-leads the Alliance for a betes, putting them at high risk for devel- and obese adults and are on a track for Healthier Generation, a oping diabetes.6 poor health throughout their adult partnership between the I After years of declines in heart disease lives.13,14,15 Overall, this generation of chil- William J. Clinton Foundation and hypertension due to the develop- dren could be the first to have shorter, and the American Heart ment of new medical treatments and less healthy lives than their parents. Association that works to drugs, these health problems are experi- Obesity also has created a major strain on advance innovative encing a resurgence. One in 4 Americans the health care system. More than a quarter approaches combating has some form of heart disease, and one of the nation’s health care costs are related in 3 Americans has high blood pressure.7 childhood obesity and helping to obesity and physical inactivity. Direct I Obesity and overweight are contributing children live healthier lives. health care costs of obesity are estimated to factors to over 20 chronic diseases, includ- be more than $61 billion annually in the “We need to continue to ing some cancers, arthritis, and even United States, while the health care costs work to create a real push Alzheimer’s disease and dementia.8, 9, 10 associated with physical inactivity topped towards reversing the obesity $76 billion in 2000.16 Our workforce has epidemic. It is time we make I Increasing evidence shows that maternal become less healthy and productive, and it a national priority,” obesity adds major complications during businesses are struggling with the increased pregnancy, putting babies at increased risk President Clinton added. costs of health insurance coverage. for pre-term birth and infant mortality.11 5 F AS IN FAT 2008 This is the fifth annual edition of F as in Fat: state. Experts estimate that if we keep on the How Obesity Policies Are Failing in America, current course, 75 percent of Americans will which tracks trends in obesity-related rates be overweight or obese by 2015.18 and policies. This report finds that much Many experts believe that America has been progress has been made during the past 5 slow to take action to deal with obesity years in bringing attention to the obesity because it has traditionally been seen as an problem and in better understanding the issue of personal responsibility. In this view reasons for the rise in obesity rates. In addi- individuals make decisions about what to eat tion, many communities and states have and how active to be, and they should bear been taking action with promising programs the burden and blame alone if they make to make physical activity and good nutrition unhealthy choices. more accessible to more Americans. But it is clear now that, while personal However, this report also concludes that responsibility is an important part of the until these promising programs are widely equation, there are many factors beyond adopted and there is a steady stream of individual control that have contributed to funding to sustain them, only limited the rising obesity rates. Some of the most progress will be made. Overall, our country significant factors include the high cost of is failing to address the obesity epidemic in healthy foods, the location of grocery stores, proportion to the threat that it poses. access to safe places to exercise, and the America’s future depends on the health of availability of preventive health care servic- our children, but we’re failing them by not es. We need to find ways to make healthy treating the obesity epidemic with the choices easy choices. And just as smoking urgency it deserves. has become less culturally acceptable, we In the past year, there has been one reason need to shift cultural norms away from for cautious optimism. According to the lat- unhealthy values like oversized portions, the est data from the U.S. Centers for Disease popularization of foods with minimum Control and Prevention’s National Health nutritional quality, and the overuse of TV and Nutrition Examination Survey and video games, which encourage physical (NHANES), after years of increases, child- inactivity. hood and adolescent obesity rates remained Addressing the obesity crisis must be a level between 2003-2004 and 2005-2006.17 It shared responsibility. This report concludes is too early to determine if this is a result of with a recommendation to create a obesity-prevention programs, but it does Nat ional St rat egy t o Combat O bes it y that provide encouragement. will involve individuals and families, com- The trends for adults continue to be even munities, schools, employers, businesses, more complicated. This year’s F as in Fat: insurers, and government to find ways to How Obesity Policies Are Failing in America address the epidemic. This strategy sets analysis finds that adult obesity rates climbed national goals, starting with a goal of revers- in 37 states. Rates did not decline in any ing the trend of childhood obesity by 2015. 6 F AS IN FAT 2008: KEY FINDINGS Obesity Rates and Related Trends I Adult obesity rates continued to rise in 37 I Obesity and obesity-related disease rates states. Rates did not decrease in any state. remain the highest in Southern states. Rates rose for a second year in a row in 24 Nine of the top 10 most obese states states, and rose for a third year in a row in were in the South. In addition, all 10 19 states. Mississippi had the highest rate states with the highest rates of diabetes -- 31.7 percent, Colorado had the lowest and hypertension, 9 of the 10 states with rate --18.4 percent. the highest rates of physical inactivity, and 8 of the 10 states with the highest rates of I More than 20 percent of adults are obese poverty are in the South. Northeastern in every state except Colorado. However, and Western states continued to have the the rate in Colorado did increase from lowest obesity rates. 17.6 to 18.4 percent. More than 25 per- cent of adults are obese in 28 states. Last I Type 2 diabetes rates rose in 26 states. In year, only 19 states had rates above 25 4 states, more than 10 percent of adults percent. And, rates now exceed 30 per- now have type 2 diabetes. cent in 3 states -- Alabama, Mississippi, and I According to the U.S. Food and Drug West Virginia. Last year, only Mississippi Administration (FDA), an estimated 50 mil- exceeded 30 percent. In 1991, no state lion Americans go on diets each year, but had an obesity rate higher than 20 per- fewer than 5 percent manage to maintain cent. In 1980, the national average of any long-term weight loss.19 obese adults was 15 percent. State Responsibilities and Policies I Currently, 40 states have plans in place I Ten states did not address nutritional assess- with specific strategies and goals to lower ment and counseling reimbursement for the prevalence of overweight, obesity and children with overweight and obesity as obesity-related chronic diseases in each part of Medicaid’s Early and Periodic state. Two states and D.C. have child- Screening, Diagnostic, and Treatment hood obesity plans, and at least 8 more (EPSDT) benefits. In these 10 states, nei- have drafts of plans in the works, which ther did the EPSDT provider manual specif- they expect to make available to the public ically mention whether Medicaid would pay over the next year or 2. for these services nor were Current Procedural Terminology (CPT) codes listed I All 50 states and D.C. have some form of leg- to bill for these services.20 In these states, it islation related to physical education and/or only can be assumed that these services are physical activity in schools, however only 13 not likely to be reimbursed. states were found to have enforceability lan- guage. Of those states, 4 included sanctions I Only 11 states provide strong evidence that or penalties within their language, and 10 they will reimburse for nutritional and behav- included collection and reporting of informa- ioral therapy in children with overweight and tion regarding performance language, with obesity as part of Medicaid’s Early and one state containing both types of language. Periodic Screening, Diagnostic, and T reatment (EPSDT) benefits, meaning the EPSDT I Of the 18 states that have school meal provider manual specifies that the state will requirements exceeding the USDA stan- pay for nutritional assessment and counseling dards, only 7 have specific enforceability and Current Procedural T erminology (CPT) language, with only one including sanctions codes are listed to bill for these services. or penalties for noncompliance. 7 F AS IN FAT 2008: KEY FINDINGS I Only 2 states’ Medicaid manuals provided the small group market. The majority used guideline references for treatment of obe- “health status” as an adjustment factor. sity in adults. L Only 9 states prohibit the use of health I Twenty-six states explicitly cover nutritional status or obesity as a factor for rate assessment and consultation for obese adults adjustments in the small group market. under Medicaid, while 20 explicitly do not. These states used community or adjusted community rating. L Drug therapy to treat obesity is the least frequently covered and discussed I Only 5 states provide for coverage of treatment category in Medicaid; only 10 one or more treatments for obesity in states cover it while 33 make no men- both the small group and individual tion of it within their provider manuals. insurance markets. The vast majority of states do not provide any coverage of L Bariatric surgery is covered by 45 state obesity related treatments and the few Medicaid plans. that do cover only those treatments for I On the group insurance market, 35 states morbid obesity do so as long as individu- expressly allow “health status” or “obesity” als adhere to the caveats imposed in the to be used as a factor for rate adjustments in coverage requirement. Obesity Related Laws Number of Number of Number of States That States That States That Had This Added This Had This Law as of Law Since Law in June 30, 2008 July 1, 2007 July 2004 Sets nutritional standards for school lunches, breakfasts, and snacks that are stricter than 18 1 2 the existing USDA requirements. Sets nutritional standards for competitive foods sold a la carte, in vending machines, in school 25 3 4 stores, or in bake sales in schools. Sets limits when and where competitive foods 27 1 23 may be sold beyond federal requirements. Sets physical education requirements. 50 + D.C. 0 50 + D.C. BMI or health information collected. 17 1 0 Sets health education requirements. 48 0 44 Taxes some foods or soft drinks that are of low 17 + D.C. 0 17 + D.C. nutritional value. Limits obesity-related liability. 24 0 11 Federal Responsibilities and Policies I The U.S. Department of Agriculture Children (WIC), adding fruits, vegetables, (USDA) school meal program has yet to and whole grains to the list of grocery adopt the recommendations from the items covered. This was the program’s national 2005 Dietary Guidelines. An esti- first major overhaul since 1974. mated 39 million children receive meals I The House and Senate overrode President through USDA school meal programs, Bush’s veto to pass into law the Food, often multiple meals (breakfast, lunch, and Conservation, and Energy Act of 2008. This possibly a snack) on weekdays. legislation reauthorizes farm and nutrition I In the past year, USDA made significant programs for the next 5 years. It includes changes to the Special Supplemental an additional $10.36 billion over current Nutrition Program for Women, Infants, and spending levels for nutrition programs. 8 Obesity Rates and Related Trends 1 SECTION T wo-thirds of American adults are either overweight or obese.21 Adult obesity rates have grown from 15 percent in 1980 to nearly 33 percent in 2003-04 based on a national survey.22 OBESITY TRENDS * AMONG U.S. ADULTS BRFSS, 1991 and 2005-2007 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 Rates of obesity continued to rise across the betes. Alabama and West Virginia also country during the past year. Thirty-seven ranked in the top 10 for highest rates of phys- states saw an increase in obesity, and 24 of ical inactivity, hypertension and diabetes. these states experienced an increase for the Now, only 22 states have rates of obesity less second year in a row. Nineteen states experi- than 25 percent, compared with 31 from last enced an increase for the third straight year. year -- losing 9 states to the 25-percent-or- Obesity rates did not decrease in a single state. greater category. In Colorado, the leanest and Last year Mississippi was the only state with only state under 20 percent, rates of obesity obesity rates over 30 percent, but this year increased from 17.6 percent to 18.4 percent. Mississippi, still ranked most obese at 31.7 The U.S. Department of Health and Human percent, has been joined by West Virginia Services (HHS) set a national goal to reduce and Alabama -- 30.6 percent and 30.1 percent adult obesity rates to 15 percent in every state respectively. Mississippi also has the highest by the year 2010. Currently, all states and the rate of physical inactivity and hypertension, District of Columbia exceed 15 percent. and tied for the second highest rate of dia- 9 CHART ON OBESITY AND OVERWEIGHT RATES ADULTS Obesity Overweight Diabetes Physical Inactivity & Obesity States 2005-2007 3 Yr. Ranking Percentage 2005-2007 2005-2007 Ranking 2005-2007 Ranking Ave. Percentage Point Change 3 Yr. Ave. 3 Yr. Ave. 3 Yr. Ave. (95% Conf Interval) 2004-2006 to Percentage Percentage Percentage 2005-2007 (95% Conf Interval) (95% Conf Interval) (95% Conf Interval) Alabama 30.1% (+/- 1.2) 3 0.7 65.4% (+/- 1.3) 10.0% (+/- 0.6)* 4 29.6% (+/- 1.1) 6 Alaska 27.3% (+/- 1.5) 14 1.5 64.5% (+/- 1.7) 5.5% (+/- 0.7)* 50 20.9% (+/- 1.4) 39 Arizona 23.3% (+/- 1.5)* 38 1.6* 59.5% (+/- 1.7)* 8.1% (+/- 0.8)** 19 22.4% (+/- 1.4) 30 Arkansas 28.1% (+/- 0.9)* 8 1.1* 64.7% (+/- 1.0)* 8.5% (+/- 0.5)* 14 29.1% (+/- 0.9) 7 California 23.1% (+/- 0.9) 41 0.4 59.4% (+/- 1.0) 7.6% (+/- 0.5) 27 23.3% (+/- 0.9) 23 Colorado 18.4% (+/- 0.7)* 51 0.8** 55.0% (+/- 0.9)* 5.1% (+/- 0.3)* 51 17.3% (+/- 0.6) 50 Connecticut 20.8% (+/- 0.8)* 49 0.7*** 58.7% (+/- 1.0)* 6.8% (+/- 0.4)* 38 20.2% (+/- 0.8) 42 Delaware 25.9% (+/- 1.2)* 21 2.4*** 63.9% (+/- 1.3)* 8.4% (+/- 0.6)* 15 22.3% (+/- 1.0) 31 D.C. 22.1% (+/- 1.0) 43 -0.1 55.0% (+/- 1.3) 7.7% (+/- 0.6) 24 21.9% (+/- 1.0) 34 Florida 23.3% (+/- 0.7) 38 0.4 60.8% (+/- 0.8)* 8.7% (+/- 0.4) 12 25.8% (+/- 0.7) 12 Georgia 27.5% (+/- 1.2)* 11 1.3* 63.3% (+/- 1.0)* 9.2% (+/- 0.5)** 9 25.5% (+/- 0.9) 14 Hawaii 20.7% (+/- 0.8) 50 0.5 55.3% (+/- 1.0)* 7.7% (+/- 0.5) 24 18.9% (+/- 0.8) 46 Idaho 24.6% (+/- 0.9)* 31 1.4* 61.4% (+/- 1.1)* 7.2% (+/- 0.5)* 33 20.6% (+/- 0.8) 40 Illinois 25.3% (+/- 0.9)* 26 0.9* 61.8% (+/- 1.1)* 8.3% (+/- 0.5)* 17 23.7% (+/- 0.9) 22 Indiana 27.5% (+/- 0.9) 11 0.6 62.8% (+/- 1.0) 8.3% (+/- 0.5) 17 25.5% (+/- 0.8) 14 Iowa 26.3% (+/- 0.9)* 19 1.4* 63.4% (+/- 1.0)* 7.0% (+/- 0.5) 35 23.0% (+/- 0.8) 25 Kansas 25.8% (+/- 0.7)* 23 1.5** 62.3% (+/- 0.8)* 7.2% (+/- 0.4)** 33 23.3% (+/- 0.7) 23 Kentucky 28.4% (+/- 1.0)* 7 1.0*** 66.8% (+/- 1.1)* 9.6% (+/- 0.6)** 7 30.7% (+/- 1.0) 4 Louisiana 29.5% (+/- 1.0)* 4 1.3* 64.2% (+/- 1.1)* 9.5% (+/- 0.5)* 8 31.4% (+/- 1.0) 2 Maine 23.7% (+/- 0.9) 34 0.6 60.8% (+/- 1.1) 7.4% (+/- 0.5) 30 21.1% (+/- 0.9) 38 Maryland 25.2% (+/- 0.8)* 27 0.8*** 61.5% (+/- 0.9)* 7.8% (+/- 0.4)* 23 23.0% (+/- 0.8) 25 Massachusetts 20.9% (+/- 0.6)* 48 1.1*** 56.8% (+/- 0.8)* 6.7% (+/- 0.3)* 41 21.8% (+/- 0.6) 35 Michigan 27.7% (+/- 0.8)* 10 0.9** 63.9% (+/- 0.9)* 8.6% (+/- 0.4)* 13 22.0% (+/- 0.7) 33 Minnesota 24.8% (+/- 1.0)* 30 1.1* 61.9% (+/- 1.2) 5.7% (+/- 0.5) 48 15.7% (+/- 0.9) 51 Mississippi 31.7% (+/- 1.0)* 1 1.1*** 67.4% (+/- 1.0)* 10.6% (+/- 0.5)* 2 31.8% (+/- 0.9) 1 Missouri 27.4% (+/- 1.1)* 13 1.1*** 63.3% (+/- 1.3) 7.7% (+/- 0.5) 24 24.7% (+/- 1.1) 18 Montana 21.7% (+/- 0.8)* 45 1.0* 59.6% (+/- 1.1)* 6.2% (+/- 0.4) 47 20.4% (+/- 0.9) 41 Nebraska 26.5% (+/- 0.9)* 18 1.1*** 63.9% (+/- 1.1)* 7.3% (+/- 0.4)** 32 22.3% (+/- 0.8) 31 Nevada 23.6% (+/- 1.3) 35 1.2 61.8% (+/- 1.5) 7.6% (+/- 0.7) 27 26.1% (+/- 1.3) 11 New Hampshire 23.6% (+/- 0.8)* 35 1.2*** 60.8% (+/- 1.0)* 7.0% (+/- 0.4) 35 20.1% (+/- 0.7) 43 New Jersey 22.9% (+/- 0.7)* 42 0.7*** 60.5% (+/- 0.9)* 8.1% (+/- 0.4)* 19 27.4% (+/- 0.7) 10 New Mexico 23.3% (+/- 0.9)* 38 1.2*** 60.3% (+/- 1.0)* 7.5% (+/- 0.5)** 29 22.5% (+/- 0.8) 28 New York 23.5% (+/- 0.8)* 37 1.2* 60.0% (+/- 1.0)* 8.0% (+/- 0.5) 21 25.8% (+/- 0.8)^ 12 North Carolina 27.1% (+/- 0.6)* 16 1.5*** 63.4% (+/- 0.7)* 8.9% (+/- 0.3) 10 24.6% (+/- 0.6) 20 North Dakota 25.9% (+/- 1.0) 21 0.8 64.5% (+/- 1.1) 6.5% (+/- 0.5) 43 22.5% (+/- 0.9) 28 Ohio 26.9% (+/- 1.1) 17 0.9 63.3% (+/- 1.2) 8.0% (+/- 0.5)* 21 24.8% (+/- 1.0) 17 Oklahoma 28.1% (+/-0.8)* 8 1.3*** 64.2% (+/- 0.9)* 9.7% (+/- 0.5)** 6 30.0% (+/- 0.8)* 5 Oregon 25.0% (+/- 0.8)* 29 1.7*** 60.8% (+/- 1.0)* 6.8% (+/- 0.4) 38 17.4% (+/- 0.7) 48 Pennsylvania 25.7% (+/- 0.8)* 24 1.2* 61.9% (+/- 1.0) 8.4% (+/- 0.5) 15 24.0% (+/- 0.8) 21 Rhode Island 21.4% (+/- 1.0)* 46 0.9*** 60.4% (+/- 1.2)* 7.0% (+/- 0.5) 35 24.7% (+/- 1.0) 18 South Carolina 29.2% (+/- 0.8)* 5 1.3*** 65.1% (+/- 0.8)* 9.8% (+/- 0.5) 5 25.1% (+/- 0.7) 16 South Dakota 26.1% (+/- 0.9)* 20 1.2*** 64.2% (+/- 1.0)* 6.5% (+/- 0.4) 43 23.0% (+/- 0.8)* 25 Tennessee 29.0% (+/- 1.2)* 6 1.2** 65.0% (+/- 1.3)* 10.6% (+/- 0.7)* 2 31.1% (+/- 1.1) 3 Texas 27.2% (+/- 0.9)* 15 0.9* 64.1% (+/- 1.0)* 8.8% (+/- 0.5)* 11 28.1% (+/- 0.9) 8 Utah 21.8% (+/- 0.9) 44 0.7 56.4% (+/- 1.2) 5.7% (+/- 0.4) 48 19.1% (+/- 0.8)* 44 Vermont 21.1% (+/- 0.7)* 47 1.1* 56.9% (+/- 0.9)* 6.3% (+/- 0.4)* 46 18.5% (+/- 0.7) 47 Virginia 25.2% (+/- 1.1) 27 0.7 61.6% (+/- 1.3) 7.4% (+/- 0.5) 30 21.6% (+/- 0.9) 37 Washington 24.5% (+/- 0.5)* 32 1.2*** 60.7% (+/- 0.6)* 6.8% (+/- 0.3)* 38 17.4% (+/- 0.4) 48 West Virginia 30.6% (+/- 1.1)* 2 0.9** 66.8% (+/- 1.1)* 11.1% (+/- 0.6) 1 27.5% (+/- 1.0)* 9 Wisconsin 25.5% (+/- 1.0) 25 0.7 62.4% (+/- 1.1) 6.4% (+/- 0.4) 45 19.1% (+/- 0.8) 44 Wyoming 24.0% (+/- 0.8)* 33 1.2*** 61.7% (+/- 1.0)* 6.6% (+/- 0.5) 42 21.8% (+/- 0.8) 35 Source: Behavior Risk Factor Surveillance System (BRFSS), CDC. To “stabilize” BRFSS data in order to rank states, TFAH combined 3 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 2004-2006 to 2005-2007 (for Hypertension figures - only collected every 2 years - from 2001-2005 to 2003-2007). **State increased significantly in the past 2 years. ***State increased significantly in the past 3 years. ^Statistically significant DECREASE. 10 AND OVERWEIGHT RATES AND RELATED HEALTH INDICATORS IN THE STATES CHILDREN AND ADOLESCENTS Hypertension Poverty 2007 YRBS 2006 PedNSS 2003-2004 National Survey of Children's Health 2003-2007 Ranking 2004-2006 Percentage of Percentage of Percentage High School Percentage Obese Percentage Obese Ranking Percentage Participating in 3 Yr. Ave. 3 Yr. Ave. Obese High School Overweight High School Students Not Meeting Low-Income Ages 10-17 Physical Activity ≥ 20 mins Percentage Percentage Students Students Recommended Physical Children Days a Week or More (95% Conf Interval) (90% Conf Interval) (95% Conf Interval) (95% Conf Interval) Activity Level Ages 2-5 3 Ages 10-17 33.5% (+/- 1.0) 2 16.0% (+/- 1.5) N/A N/A N/A 13.70% 16.70% 11 77.60% 23.9% (+/- 1.4)* 48 9.3% (+/- 1.3) 11.1% (+/-2.2) 16.2% (+/- 2.7) 57.50% N/A 11.10% 44 75.50% 24.2% (+/- 1.2) 46 14.7% (+/- 1.4) 11.7% (+/- 2.5) 14.2% (+/- 2.3) 68.00% 13.50% 12.20% 38 72.70% 31.5% (+/- 0.9)* 5 15.6% (+/- 1.6) 13.9% (+/- 2.5) 15.8% (+/- 2.3) 58.00% 13.20% 16.40% 12 71.90% 27.2% (+/- 0.9)** 24 12.9% (+/- 0.5) N/A N/A N/A 17.00% 13.20% 32 74.90% 21.7% (+/- 0.7) 50 10.4% (+/- 1.4) N/A N/A N/A 9.60% 9.90% 49 70.40% 25.7% (+/- 0.8)** 35 9.1% (+/- 1.3) 12.3% (+/-1.6) 13.3% (+/- 1.9) 54.90% 16.20% 12.30% 37 68.50% 29.2% (+/- 1.1)* 13 9.2% (+/- 1.3) 13.3% (+/- 1.6) 17.5% (+/- 1.7) 59.60% N/A 14.80% 19 65.70% 27.9% (+/- 1.2) 20 18.8% (+/- 2.0) 17.7% (+/- 2.0) 17.8% (+/- 2.1) 69.80% 15.40% 22.80% 1 62.10% 29.3% (+/- 0.9)* 12 11.4% (+/- 0.7) 11.2% (+/- 1.4) 15.2% (+/- 1.3) 61.60% 13.90% 14.40% 21 68.90% 29.4% (+/- 0.8)* 11 13.3% (+/- 1.0) 13.8% (+/- 2.0) 18.2% (+/- 2.1) 56.20% 14.50% 16.40% 12 69.10% 26.1% (+/- 0.9)* 30 8.8% (+/- 1.2) 15.6% (+/- 2.9) 14.3% (+/- 2.7) 65.70% N/A 13.30% 29 75.20% 25.4% (+/- 0.9)* 39 9.8% (+/- 1.3) 11.1% (+/- 1.7) 11.7% (+/- 2.6) 53.20% 12.40% 10.10% 47 70.50% 26.7% (+/- 0.9)* 28 11.5% (+/- 0.8) 12.9% (+/- 2.1) 15.7% (+/- 2.0) 56.50% 14.40% 15.80% 14 71.10% 28.1% (+/-0.8)* 19 11.6% (+/- 1.2) 13.8% (+/-2.0) 15.3% (+/- 1.8) 56.30% 14.00% 15.60% 15 70.70% 26.3% (+/- 0.8) 29 10.8% (+/- 1.4) 11.3% (+/- 3.1) 13.5% (+/- 2.2) 50.10% 14.60% 12.50% 35 74.80% 25.6% (+/- 0.7)** 36 12.2% (+/- 1.5) 11.1% (+/- 2.0) 14.4% (+/- 2.2_ 54.90% 13.80% 14.00% 24 76.60% 30.1% (+/- 0.9) 9 16.5% (+/- 1.6) 15.6% (+/- 1.7) 16.4% (+/- 1.6) 67.10% 17.40% 20.60% 3 68.40% 30.9% (+/- 1.0)** 7 17.4% (+/- 1.7) N/A N/A N/A N/A 17.20% 9 75.20% 27.6% (+/- 1.0)* 22 11.5% (+/- 1.5) 12.8% (+/- 2.7) 13.1% (+/- 2.4) 56.90% N/A 12.70% 34 67.30% 27.7% (+/- 0.8)* 21 9.3% (+/- 1.1) 10.9% (+/- 2.4) 15.2% (+/- 2.8) 69.40% 14.80% 13.30% 29 61.70% 25.8% (+/- 0.6)** 33 10.5% (+/- 1.1) 11.1% (+/- 1.6) 14.6% (+/- 2.0) 59.00% 16.70% 13.60% 27 67.60% 28.7% (+/- 0.8)** 16 12.9% (+/- 1.0) 12.4% (+/- 2.0) 16.5% (+/- 2.0) 56.00% 13.30% 14.50% 20 69.60% 22.6% (+/- 0.9) 49 7.7% (+/- 1.1) N/A N/A N/A 13.10% 10.10% 47 72.80% 34.5% (+/- 0.9)* 1 19.8% (+/- 1.7) 17.9% (+/- 2.5) 17.9% (+/- 1.9) 63.90% N/A 17.80% 8 69.40% 29.1% (+/- 1.1)** 15 11.7% (+/- 1.2) 12.0% (+/- 3.0) 14.3% (+/- 1.5) 56.50% 13.60% 15.60% 15 72.10% 24.5% (+/- 0.9) 45 13.8% (+/- 1.5) 10.1% (+/- 1.1) 13.3% (+/- 1.3) 55.10% 12.10% 11.10% 44 76.40% 25.5% (+/- 0.8)** 37 9.7% (+/- 1.3) N/A N/A N/A 13.10% 11.90% 41 74.20% 26.0% (+/- 1.2) 31 10.4% (+/- 1.4) 11.0% (+/- 2.3) 14.5% (+/- 1.9) 53.80% 14.00% 12.40% 36 72.60% 24.9% (+/- 0.7)* 43 5.5% (+/- 1.0) 11.7% (+/- 2.0) 14.4% (+/-2.0) 53.10% 15.90% 12.90% 33 68.10% 27.2% (+/- 0.7)* 24 7.9% (+/- 0.8) N/A N/A N/A 18.10% 13.70% 26 66.80% 24.0% (+/- 0.8)** 47 17.1% (+/- 1.8) 10.9% (+/- 2.0) 13.5% (+/- 2.1) 56.40% 11.50% 16.80% 10 69.90% 27.0% (+/- 0.8) 26 14.5% (+/- 0.8) 10.9% (+/- 1.1) 16.3% (+/- 1.3) 62.00% 15.30% 15.30% 18 68.20% 29.8% (+/- 0.7)** 10 13.8% (+/- 1.1) 12.8% (+/- 2.4) 17.1% (+/- 1.9) 55.70% 15.40% 19.30% 5 74.40% 25.1% (+/- 0.9)* 42 10.8% (+/- 1.4) 10.0% (+/- 1.9) 13.7% (+/- 3.3) 52.20% N/A 12.10% 39 75.40% 28.2% (+/- 0.9)* 17 12.0% (+/- 0.9) 12.4% (+/- 2.2) 15.0% (+/-3.3) 55.30% 11.70% 14.20% 22 69.90% 30.7% (+/- 0.7)** 8 13.9% (+/- 1.5) 14.7% (+/- 1.9) 15.2% (+/- 1.9) 50.40% N/A 15.40% 17 73.30% 25.5% (+/- 0.8)* 37 11.9% (+/- 1.5) N/A N/A N/A 14.30% 14.10% 23 77.00% 28.2% (+/- 0.8) 17 11.3% (+/- 0.8) N/A N/A N/A 11.10% 13.30% 29 67.90% 29.2% (+/- 1.0)** 13 11.3% (+/- 1.5) 10.7% (+/- 2.2) 16.2% (+/- 1.8) 58.10% 16.50% 11.90% 41 63.80% 31.3% (+/- 0.7)** 6 13.7% (+/- 1.5) 14.4% (+/- 2.9) 17.1% (+/- 2.3) 62.00% 13.70% 18.90% 7 67.50% 25.8% (+/- 0.7)* 33 12.0% (+/- 1.3) 9.1% (+/- 2.6) 14.5% (+/- 2.1) 56.00% 14.30% 12.10% 39 73.20% 32.1% (+/- 1.1)* 4 15.2% (+/- 1.3) 16.9% (+/- 2.0) 18.1% (+/- 2.1) 58.00% 13.10% 20.00% 4 65.10% 26.9% (+/- 0.7)* 27 16.4% (+/- 0.8) 15.9% (+/- 2.1) 15.6% (+/- 2.0) 54.80% 15.60% 19.10% 6 73.90% 20.3% (+/- 0.8) 51 9.5% (+/- 1.2) 8.7% (+/- 3.8) 11.7% (+/- 2.5) 52.50% N/A 8.50% 51 71.70% 24.6% (+/- 0.8)** 44 7.7% (+/- 1.3) 11.8% (+/-3.3) 14.5% (+/- 2.8) 52.00% 12.90% 11.30% 43 73.50% 27.3% (+/- 1.0)** 23 9.1% (+/- 1.0) N/A N/A N/A 17.00% 13.80% 25 72.50% 25.4% (+/- 0.4)* 39 9.9% (+/- 1.1) N/A N/A N/A 14.20% 10.80% 46 72.90% 33.2% (+/- 1.0) 3 15.0% (+/- 1.5) 14.7% (+/- 2.4) 17.0% (+/- 3.2) 57.20% 12.70% 20.90% 2 77.10% 25.9% (+/- 0.9)* 32 10.9% (+/- 1.2) 11.1% (+/- 1.6) 14.0% (+/- 1.4) 61.70% 13.00% 13.50% 28 75.10% 25.2% (+/- 0.8)* 41 10.2% (+/- 1.4) 9.3% (+/-1.5) 11.4% (+/- 1.4) 51.80% N/A 8.70% 50 76.80% Source: U.S. Census Source: Youth Risk Behavior Survey (YRBS) 2007, CDC. YRBS data are collected every 2 years. Percentages are as reported on the CDC website and can be found at Bureau, Current <http://www.cdc.gov/HealthyYouth/yrbs/index.htm>. Note that previous YRBS reports used the term “overweight” to describe youth with a BMI at or above the 95th Population Survey, 2005 to percentile for age and sex and “at risk for overweight” for those with a BMI at or above the 85th percentile, but below the 95th percentile. However, this report uses the 2007 Annual Social and terms “obese” and “overweight” based on the 2007 recommendations from the Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Economic Supplements. Overweight and Obesity convened by the American Medical Association. Students “not meeting recommended levels of physical activity” is the difference between <http://www.census.gov/ 100 percent and the percentage of students “who met recommended levels of physical activity.” • Source: 2006 National PedNSS Tables, number 6D, available at: hhes/www/poverty/poverty <http://www.cdc.gov/pednss/pednss_tables/pdf/national_table6.pdf>.Source: National Survey of Children's Health, 2003. Overweight and Physical Activity Among 06/state.html> Children: A Portrait of States and the Nation 2005, Health Resources and Services Administration, Maternal and Child Health Bureau. 11 Southern states continue to fill the top 10 most obese states in the country, with the exception of Michigan. Mississippi, West Virginia and Alabama stayed in the same positions as last year. States with the Highest Obesity Rates Rank State Percentage of Adult Obesity (Based on 2005-2007 Combined Data, Including Confidence Intervals) 1 Mississippi 31.7% (+/- 1.0) 2 West Virginia 30.6% (+/- 1.1) 3 Alabama 30.1% (+/- 1.2) 4 Louisiana 29.5% (+/- 1.0) 5 South Carolina 29.2% (+/-0.8) 6 Tennessee 29.0% (+/-1.2) 7 Kentucky 28.4% (+/- 1.0) 8 (tie) Oklahoma 28.1% (+/- 0.8) 8 (tie) Arkansas 28.1% (+/- 0.9) 10 Michigan 27.7% (+/- 0.8) Northeastern and Western states continue to dominate the states with the lowest rates of obesity, this year D.C. and New Jersey replaced Arizona and New Mexico. States With the Lowest Obesity Rates Rank State Percentage of Adult Obesity (Based on 2005-2007 Combined Data, Including Confidence Intervals) 51 Colorado 18.4% (+/- 0.7) 50 Hawaii 20.7% (+/- 0.8) 49 Connecticut 20.8% (+/- 0.8) 48 Massachusetts 20.9% (+/- 0.6) 47 Vermont 21.1% (+/-0.7) 46 Rhode Island 21.4% (+/-1.0) 45 Montana 21.7% (+/- 0.8) 44 Utah 21.8% (+/- 0.9) 43 District of Columbia 22.1% (+/- 1.0) 42 New Jersey 22.9% (+/- 0.7) Rates and Rankings Methodology The rates and rankings in the tables are based on comparisons of The data are based on telephone surveys conducted by state health 2004-2006 to 2005-2007 Behavioral Risk Factor Surveillance System departments with assistance from CDC where individuals self-report (BRFSS) data. TFAH uses 3 years of BRFSS data in order to stabilize their weight and height. Researchers then use these statistics to cal- the data by using large enough sample sizes for comparisons among culate body mass index (BMI) to determine obesity or overweight. states and over time based on advice of officials from the U.S. Since the survey is based on self-reporting, experts feel the rates are Centers for Disease Control and Prevention (CDC). In order for a likely to be slightly underreported, since individuals tend to underre- state rate to be considered to have an increase, the change must port their weight and over report their height. reach a level of what experts consider to be statistically significant More information about the methodology of the rankings is available (p<0.05) for the particular sample size of that state. in Appendix A. The District of Columbia is included in the state rankings, since CDC funds D.C. to conduct a survey in an equivalent way to the states. 12 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.23,24 Overweight refers to increased body weight in relation to height, which is then compared to a standard of acceptable weight.25 Body mass index, or BMI, is a common measure expressing the relationship (or ratio) of weight-to-height. The equation is: BMI = (Weight in pounds) x 703 (Height in inches) x (Height in inches) Adults with a BMI of 25 to 29.9 are considered health of an individual.30 A study conducted overweight, while individuals with a BMI of 30 in 1998 and recently reported on by the or more are considered obese. The National Harvard Medical School showed that Institutes of Health (NIH) adopted a lower opti- women with a healthy-weight BMI are more mal weight threshold in June 1998. Previously, likely to suffer from coronary disease if their the federal government defined overweight as a waist circumference is too high.31 The prob- BMI of 28 for men and 27 for women. lem that doctors have encountered is finding a formula for waist circumference, because Until recently children and youth at or above the numbers based on averages do not take the 95th percentile were defined as “over- height into account. The International weight”, while children at or above the 85th Journal of Obesity recently reported that the percentile but below the 95th percentile were waist-to-height ratio might be a better indi- defined as “at risk of overweight”. However, cator of health. Using this measure, an in 2007, an expert committee recommended adult’s waist circumference should be less using the same cut points but changing the than half of his or her height.32 terminology by replacing “overweight” with “obese” and “at risk of overweight” with Examining BMI levels, however, is still consid- “overweight”. The committee also added an ered useful by a number of researchers for additional cut point -- BMI at or above the examining trends and patterns of overweight 99th percentile -- to define “severe obesity.”26 and obesity. There are some issues and disputes sur- The strengths of the BMI measure include: rounding the use of BMI as the primary measure for obesity, including: I Correlates with body fat; I Easy to measure; I BMI does not distinguish between fat and muscle, and individuals with a significant I Noninvasive; amount of lean muscle will have higher BMIs I Less expensive than other more invasive which do not indicate an unhealthy level of fat. techniques; I Research has shown that those of African I Good sensitivity and specificity; and/or Polynesian ancestry may have less I Most recommended measure; body fat and leaner muscle mass, suggest- ing higher baseline BMIs for overweight I There is U.S. reference data so it can be and obesity.27 used to track trends; I Research has also found that there may be I Child BMI correlates with adult adiposity33; other race or ethnicity issues in BMI meas- and urements. A June 2005 study found that I Correlates with cardiovascular risk factors current BMI thresholds “significantly under- and long-term mortality.34,35 estimate health risks in many non- Many experts, however, recommend assessing Europeans.”28 Asian and Aboriginal groups, an individual’s health using factors in addition despite “healthy” BMIs, had high risk of to BMI, such as waist size, waist-to-hip ratio, “weight related health problems.”29 Several blood pressure, cholesterol level, and blood years ago, it was suggested to the World sugar.36 Recently, an expert panel consisting of Health Organization (WHO) that BMI levels 15 health organizations recommended that be dropped to 23 and 25 for overweight physicians and allied healthcare providers per- and obesity, respectively, among Asian popu- form, at a minimum, a yearly assessment of lations, but no such changes have occurred. weight status in all children, and that this I Recent studies have shown that for adults, assessment should include calculation of waist circumference is another, and perhaps height, weight, and BMI for age and plotting better, way to determine more about the those measures on a standard growth chart.37 13 B. CHILDHOOD AND YOUTH OBESITY AND OVERWEIGHT RATES 1. Study of Children and Adolescents Age 2 to 19 Years Old According to a recent analysis of data from increases. Researchers at CDC report that the National Health and Nutrition there was no statistically significant change Examination Survey (NHANES), the num- in the number of children and adolescents ber of U.S. children who are overweight or (aged 2 to 19) with high BMI for age obese may have peaked, after years of steady between 2003-2004 and 2005-2006.38 Percentage of Children Age 2-19 Classified as Overweight or Obese, and Obese Source: National Health and Nutrition Examination Survey data This is the first time the rates have not remains far too high and the public health increased in over 25 years. Scientists and toll of childhood obesity will continue to public health officials, however, are unsure grow as the problems related to overweight if the data reflect the effectiveness of recent and obesity in children show up later in life. public health campaigns to raise awareness Scientists expect to know more when the 2007- about obesity and increased physical activity 2008 NHANES data are analyzed. The 2005- and healthy eating among children and ado- 2006 National Survey on Children’s Health, a lescents, or if this a statistical abnormality.39 large national survey with state-specific data, is Even if childhood obesity rates have peaked, also due out in late 2008 and may offer anoth- the number of children with unhealthy BMIs er perspective on childhood obesity rates. 14 2. Study of 10- to 17-Year Olds Proportion of Children Age 10-17 Classified as Obese, by State Source: National Survey on Children’s Health, 2003. According to a 2003-2004 National Survey in Utah to 22.8 percent in D.C. Eight of the of Children’s Health (NSCH), childhood 10 states with the highest rates of obese chil- obesity rates for children age 10-17, defined dren are in the South. The NSCH study is as BMI greater than 95th percentile BMI for based on a survey of parents in each state. age group, ranged from a low of 8.5 percent States with Highest Rates of Obese 10- to 17-Year Olds Ranking States Percentage of Obese 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% 15 Six of the states with the lowest rates of obese 10- to 17-year olds are in the West. States With Lowest Rates of Obese 10- to 17-Year Olds Ranking States Percentage of Obese 10- to 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 nearly 50 method, and conducted by the National Center percent to nearly 65 percent, depending on the for Health Statistics using the same random state. Data were weighted according to a vari- digit dialing sampling frame as the National ety of socio-economic measures to ensure an Immunization Survey.40 Data were collected accurate picture of the population. State-level from the parent or guardian “who was most estimates have a margin of error of up to 3 knowledgeable about the health and health percent, 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 2003 to July 2004. rather than actual differences in measurement. 3. Survey of High School Students According to the 2007 national Youth Risk In 2007, YRBS data from 39 states indicated Behavior Survey (YRBS), a survey of U.S. that obesity rates among high school stu- high school students, 13 percent of students dents ranged from a low of 8.7 percent in are obese and 15.8 percent of students are Utah to a high of 17.9 percent in Mississippi, overweight.41 Although these numbers were with a median obesity rate of 12 percent. virtually unchanged since the 2005 national Overweight rates among high school stu- YRBS, the latest biennial survey did reveal an dents ranged from a low of 11.4 percent in upward trend from 1999 to 2007 in the preva- Wyoming to a high of 18.2 percent in lence of students nationwide who were obese Georgia, with a median overweight rate of (10.7 percent to 13.0 percent) and who were 15.0 percent. Thirty-nine states and D.C. overweight (14.4 percent to 15.8 percent). participated in the survey Percentage of Obese and Overweight U.S. High School Students by Sex Obese Overweight Female 9.6% 15.1% Male 16.3% 16.4% Total 13.0% 15.8% 16 Percentage of Obese and Overweight U.S. High School Students by Race/Ethnicity Obese Overweight White* 10.8% 14.3% Black* 18.3% 19.0% Hispanic 16.6% 18.1% Total 13.0% 15.8% *Note: Non-Hispanic Percentage of Obese and Overweight U.S. High School Students by Sex and Race/Ethnicity Obese Overweight Female Male Female Male White* 6.8% 14.6% 12.8% 15.7% Black* 17.8% 18.9% 21.4% 16.6% Hispanic 12.7% 20.3% 17.9% 18.3% Total 9.6% 16.3% 15.1% 16.4% *Note: Non-Hispanic Methodology for the Youth Risk Behavior Surveillance System The Youth Risk Behavior Surveillance System Minnesota, Pennsylvania, Virginia, and (YRBSS) monitors 6 categories of priority Washington) and some states that do conduct health-risk behaviors among youth and young a YRBS did not have weighted data (in 2007, adults. The YRBSS includes national, state, these states were: Alabama, Colorado, and local Youth Risk Behavior Surveys (YRBS) Nebraska, New Jersey, and Oregon). TFAH conducted biennially among representative reported the percentage of obese and over- samples of high school students. The 2007 weight high school students based on infor- data in this report are from the national YRBS mation from CDC. All data reported in this and separate YRBSs conducted in 39 states. section can be found in the article “Youth Risk Data are not available from every state Behavior Surveillance -- United States, 2007” because some do not conduct a YRBS (in published in Morbidity and Mortality Weekly 2007, these states were: California, Louisiana, Report 57, no. SS-4 (2008): 1-136. 4. Study of Low-Income Children Aged 2-5 A survey of low-income children aged 2-5 these children are obese and 16.4 percent called the Pediatric Nutrition Surveillance are overweight.42 Forty states and D.C. par- Survey (PedNSS) found that 14.8 percent of ticipated in the survey. Methodology for the Pediatric Nutrition Surveillance Survey TFAH used PedNSS data as a snapshot of and tribal governments, and then reported to overweight and obesity among low-income and published by CDC. Data are collected pre-school aged children. These data are col- yearly and are available at lected at public health clinics across the coun- http://www.cdc.gov/pednss. try, are aggregated by the state, territorial, 17 CHILD AND ADOLESCENT HEALTH SURVEYS In the 2008 report, TFAH highlights data from The Pediatric Nutrition Surveillance Survey is 4 separate child and adolescent health surveys. designed to collect data on overweight and obesity among low-income pre-school aged The National Health and Nutrition children. Examination Survey (NHANES) is designed to study national trends and data and is con- The 4 studies collect information in different sidered the gold standard. ways and, therefore, have different results that are difficult to compare. For example, the The National Survey of Children’s Health NSCH numbers are usually lower, because the (NSCH) uses data collected from the parent survey design is based on data collected from or guardian and provides state-level estimates parents about their children. Parents, especially of children’s health statistics, including obesity. those of young children, tend to underreport The Youth Risk Behavior Surveillance weight. NHANES data, meanwhile, are collect- System (YRBSS) collects data on health-risk ed through in-person interviews and physician behaviors among youth and young adults. examinations. Obesity is calculated using actual The YRBSS is unique because of its state- height and weight measurements, rather than level, grade-level, and racial and ethnic self-reported data; because of this, the NHANES specific data. is often referred to as the “gold standard.” C. PHYSICAL INACTIVITY IN ADULTS Six states reported an increase is physical inac- lower rate of physical inactivity than last year. tivity in the past year, up from only 3 reporting Overall, rates of physical inactivity appear to an increase in last year’s report. Physical inac- be stagnant, with the majority of states not tivity rates for adults reflect the number of sur- demonstrating any statistically significant vey respondents who reported not engaging change in their rates of physical inactivity. in physical activity or exercise during the pre- Mississippi, the state with the highest rate of vious 30 days other than their regular jobs. obesity, also had the highest reported per- While the 2004-2006 data showed that 5 centage of physical inactivity at 31.8 per- states had decreased rates of physical inactiv- cent. Southern states dominate the highest ity -- i.e. more people reported being rates of physical inactivity, with the excep- engaged in physical activity -- the 2005-2007 tion of New Jersey. data show only one state, New York, with a States with the Highest Rates of Physical Inactivity Rank State Percentage of Adult Physical Obesity Ranking Inactivity (Based on 2005-2007 Combined Data, Including Confidence Intervals) 1 Mississippi 31.8% (+/- 0.9) 1 2 Louisiana 31.4% (+/- 1.0) 4 3 Tennessee 31.1% (+/-1.1) 6 4 Kentucky 30.7% (+/-1.0) 7 5 Oklahoma 30.0% (+/-0.8) 8 6 Alabama 29.6% (+/-1.1) 3 7 Arkansas 29.1% (+/-0.9) 8 8 Texas 28.1% (+/-0.9) 15 9 West Virginia 27.5% (+/-1.0) 2 10 New Jersey 27.4% (+/-0.7) 42 18 Minnesota stays at the bottom of the rank- the previous year’s rate. All 10 states with ings with 15.7 percent of adults reporting the lowest rates of physical inactivity remain physical inactivity -- statistically the same as the same as last year’s report. States with the Lowest Rates of Physical Inactivity Rank State Percentage of Adult Physical Obesity Ranking Inactivity (Based on 2005-2007 Combined Data, Including Confidence Intervals) 51 Minnesota 15.7% (+/- 0.9) 30 50 Colorado 17.3% (+/-0.6) 51 48 Washington 17.4% (+/-0.4) 32 48 Oregon 17.4% (+/-0.7) 29 47 Vermont 18.5% (+/-0.7) 47 46 Hawaii 18.9% (+/-0.8) 50 44 Wisconsin 19.1% (+/-0.8) 25 44 Utah 19.1% (+/-0.8) 44 43 New Hampshire 20.1% (+/-0.7) 35 42 Connecticut 20.2% (+/-0.8) 49 D. DIABETES AND HYPERTENSION Obesity and physical inactivity have been tension are also in the top 10 states with the shown to be related to a range of chronic highest rates of obesity. Diabetes rates rose diseases, including diabetes and hyperten- in 26 states and 7 states experienced an sion. Eight of the 10 states with the highest increase in diabetes rates for the second rates of adult diabetes are also in the top 10 straight year. Hypertension rates rose in 38 states with the highest obesity rates, and 9 of states and 15 states had an increase in hyper- the 10 states with the highest rates of hyper- tension rates 2 years in a row. 1. Diabetes West Virginia, for the second year in a row, at 5.1 percent. All 10 states with the highest had the highest rate of adult diabetes at 11.1 rates of adult diabetes are in the South. percent, while Colorado had the lowest rate States with the Highest Rates of Adult Diabetes Rank State Percentage of Adult Diabetes Obesity Ranking (Based on 2005-2007 Combined Data, Including Confidence Intervals) 1 West Virginia 11.1% (+/-0.6 ) 2 2 (tie) Tennessee 10.6% (+/-0.7 ) 6 2 (tie) Mississippi 10.6% (+/-0.5 ) 1 4 Alabama 10.0% (+/-0.6 ) 3 5 South Carolina 9.8% (+/-0.5) 5 6 Oklahoma 9.7% (+/-0.5) 8 7 Kentucky 9.6% (+/-0.6) 7 8 Louisiana 9.5% (+/-0.5) 4 9 Georgia 9.2% (+/-0.5) 11 10 North Carolina 8.9% (+/-0.3) 16 19 2. Hypertension For the third year in a row, Mississippi led percent, had the lowest rate for the third the nation with the highest rate of hyper- year in a row. All 10 states with the highest tension, at 34.5 percent, while Utah, at 20.3 rates of adult hypertension are in the South. States with the Highest Rates of Adult Hypertension Rank State Percentage of Adult Hypertension Obesity Ranking (Based on 2003-2007 Combined Data, Including Confidence Intervals) Based on a Survey Conducted Every Other Year 1 Mississippi 34.5% (+/- 0.9) 1 2 Alabama 33.5% (+/- 1.0) 3 3 West Virginia 33.2% (+/-1.0) 2 4 Tennessee 32.1% (+/-1.1) 6 5 Arkansas 31.5% (+/-0.9) 8 (tie) 6 South Carolina 31.3% (+/-0.7) 5 7 Louisiana 30.9% (+/-1.0) 4 8 Oklahoma 30.7% (+/-0.7) 8 (tie) 9 Kentucky 30.1% (+/-0.9) 7 10 North Carolina 29.8% (+/-0.7) 16 E. OBESITY AND POVERTY Obesity rates also appear to have some rela- ty rates. Eight out of the 10 states with the tionship with poverty rates in many states, highest rates of poverty are in the South, where although there are notable exceptions. Seven obesity rates are also higher, while many of the of the states with the highest poverty rates are states with the lowest poverty rates are among also in the top 10 states with the highest obesi- the states with the lowest rates of obesity. States with the Highest Poverty Rates and Their Obesity Rankings Poverty State Percentage of Poverty (Based on Obesity Ranking Rank 2004-2006 Combined Data, Including Confidence Intervals) 1 Mississippi 19.8% (+/- 1.7) 1 2 D.C. 18.8% (+/- 2.0) 43 3 Louisiana 17.4% (+/- 1.7) 4 4 New Mexico 17.1% (+/- 1.8) 38 5 Kentucky 16.5% (+/- 1.6) 7 6 Texas 16.4% (+/- 0.8) 15 7 Alabama 16.0% (+/- 1.5) 3 8 Arkansas 15.6% (+/- 1.6) 8 9 Tennessee 15.2% (+/- 1.3) 6 10 West Virginia 15.0% (+/- 1.5) 2 20 States with the Lowest Poverty Rates and Their Obesity Rankings Poverty State Percentage of Poverty Obesity Ranking Rank (Based on 2004-2006 Combined, Including Confidence Intervals) 51 New Hampshire 5.5% (+/- 1.0) 35 49 (tie) Minnesota 7.7% (+/- 1.1) 30 49 (tie) Vermont 7.7% (+/- 1.3) 47 48 New Jersey 7.9% (+/- 0.8) 42 47 Hawaii 8.8% (+/- 1.2) 50 45 (tie) Connecticut 9.1% (+/- 1.3) 49 45 (tie) Virginia 9.1% (+/- 1.0) 27 44 Delaware 9.2% (+/- 1.3) 21 42 (tie) Alaska 9.3% (+/- 1.3) 14 42 (tie) Maryland 9.3% (+/- 1.1) 27 WHY NATIONAL AND STATE DATA ARE DIFFERENT: 2 DIFFERENT SURVEYS The CDC conducts 2 separate information women are more likely to report that they surveys about health statistics. weigh less than they do while men are more likely to say that they are taller than they are, The National Health and Nutrition it is commonly believed that BRFSS underre- Examination Survey (NHANES) is designed ports obesity.43 Although the BMI data gath- to study national trends and data. The ered in the BRFSS may not be completely Behavioral Risk Factor Surveillance Survey accurate, the main purpose of this surveillance (BRFSS) studies trends and data in each state. is to monitor trends and there are no method- The 2 studies collect information in different ological issues with this, that is, the tendency ways and, therefore, have different results. to report a lower weight or higher height like- The BRFSS numbers are usually lower, ly remains constant every year. because the survey design is based on self- Despite these limitations, BRFSS is the best reported information, whereas NHANES data available source of data on health trends in are collected through in-person interviews states and local areas. This taxpayer sup- and physician examinations. The number typ- ported CDC program is the only source that ically cited for the national adult obesity rate collects state-by-state health information on a is 32 percent using the NHANES data. This regular basis. number is higher than the estimated percent- age for many states, which use BRFSS. CDC provides BRFSS information to policy- makers, including Congress and state officials, NHANES is a nationally representative sur- and to the public. CDC presents this informa- vey. Obesity is calculated using actual height tion routinely through charts, its Web site, and and weight measurements, rather than self- trend maps. These data provide the opportu- reported data; because of this, the NHANES nity to review trends and patterns. As hap- is often referred to as the “gold standard.” pens in this report, sometimes CDC presents BRFSS is based on state rather than national this data without confidence intervals for the representation and is a telephone survey sake of clarity; however, additional information where respondents self-report their height, with more detail, including sample sizes, confi- weight, and other health information. It is the dence intervals, limitations, and data quality, is only source for state-level health information. available to the public on CDC’s Web site at According to CDC, BRFSS is the largest phone ftp://ftp.cdc.gov/pub/Data/Brfss/2007Summary survey in the world. Because data show that DataQualityReport.pdf. WHY RANK STATES? TFAH provides state rankings to better inform concern and action on obesity in different policymakers and the public about obesity areas of the country. Due to annual variations trends in the United States. The information in the data, and based on advice from CDC allows people to gain a better understanding of officials, TFAH stabilizes the data by combining patterns in rising obesity rates. State rankings 3 years. This is similar to how NHANES com- also help demonstrate the varying levels of bines 3 years of data to stabilize any anomalies. 21 Fast Facts About Obesity A. WHAT’S BEHIND THE OBESITY EPIDEMIC? MANY ISSUES INFLUENCE NUTRITION AND PHYSICAL ACTIVITY BEHAVIORS 2 SECTION Food Choices and Changes I Higher caloric intake -- Adults consumed approximately 300 more calories daily in 2002 than they did in 1985.44 I Higher caloric density of foods. I Limited access to supermarkets and nutritious, fresh foods in many urban and rural neighborhoods. I “Portion distortion,” or the rise of bigger portions. I “Value sizing” or placing a higher value on the amount of food versus the quality of food. I Less in-home cooking and more frequent reliance on take-out food and eating in restaurants. I The proliferation of microwaves and faster, easier to prepare foods. Schools I A variety of food and beverage options are available throughout the school day including soda, fruit drinks that are not 100 percent juice, high energy dense foods, and fast food. These foods and beverages are available at venues such as a la carte lines, school stores, snack machines, fundraisers, and classroom parties. I Reduction in the amount of physical education, recess, and recreation time. I Few safe routes to school. I Limited health education classes. I Lack of opportunities to participate in physical activity that are lifelong in nature. Communities Not Designed for Physical Activity I Communities designed to foster driving rather than walking or biking. I Lack of public transportation options. I Poor upkeep of sidewalk infrastructure. I Walking areas often unsafe or inconvenient. I Limited parks and recreation space, including indoor facilities. I Poor upkeep and security in local parks. I Weather conditions limit outdoor physical activity options. I Lack of affordable indoor physical activity options. Marketing and Advertising I Greater advertising and marketing of less nutritious foods. I Marketing of “fad” diets. Workplaces Not Conducive to Health I Many desk jobs limit or discourage activity, part of the sedentary lifestyle. I Worksites typically not designed to foster movement. I Limited opportunities for physical activity or recreation during the work day. I Unhealthy options in cafeterias or work lunch sites. I Lack of bike racks and/or shower facilities discourage active transportation. 23 Economic Constraints I Health insurance coverage for obesity-prevention services is often limited or not available. I People without health insurance often do not receive either appropriate preventive servic- es or follow-up care. I “Value sizing” of less nutritious foods and the higher costs of many nutritious foods. I Expense of and taxes on gym memberships, exercise classes, equipment, facility use, and sports league fees. I Lower-income neighborhoods have fewer and smaller grocery stores and less access to affordable fruits and vegetables. Family and Home Influences I Influence of other family members’ habits on eating and exercise patterns. I “Electronic culture” options for entertainment and free time, including TV, video games, and the Internet. I More people working outside the home or far from home. Limited Time I Long work hours mean more meals -- many of them high in calories - are eaten outside of the home. I Car time and commuting cut into free time that could be used for physical activity. Genetics, Physiology, and Life Stages I Metabolism. I Childbearing. I Increased risk factors for obesity and related diseases in children with obese parents, particularly mothers. I Aging factors, including menstruation, pre-menopause, and menopause for women. I Weight-gain as a side effect from some commonly used medications such as insulin, antiretrovirals, antidepressants, oral contraceptives, and injectable contraceptives. Psychology I Body image concerns. I Consumers’ frustration with conflicting nutrition information and advice. I Eating to combat stress. I Turning to eating as a replacement for smoking or other unhealthy behaviors. 24 B. OBESITY’S IMPACT ON HEALTH HEALTH IMPACT OF OBESITY AND PHYSICAL INACTIVITY Below are some key findings based on a range of research into the health impact of obesity on adult and child health. Physical activity has been shown to have a role in reversing or preventing many of these health problems. I Type 2 Diabetes L More than 80 percent of people with type L CDC projects that 48.3 million Americans 2 diabetes are overweight.45 will have diabetes by 2050.51 L More than 20 million adult Americans L Approximately 176,500 individuals under have diabetes.46 the age of 20 have diabetes.52 L Another 54 million Americans are L Two million adolescents aged 12-19 are pre-diabetic, which means they have pre-diabetic.53 prolonged or uncontrolled elevated L The National Institute of Diabetes and blood sugar levels that can contribute Digestive and Kidney Diseases found that to the development of diabetes.47 a 7-percent weight loss together with L Diabetes is the seventh leading cause of moderate levels of physical activity (walk- death in the United States and accounts for ing 30 minutes a day 5 days a week) 11 percent of all U.S. health care costs.48, 49 decreased the number of new diabetes L Diabetes is the leading cause of renal failure, type 2 cases by 58 percent.54 limb amputations and blindness.50 THE EMERGING TREND OF TYPE 2 DIABETES IN CHILDREN Type 2 diabetes is a chronic disease that other primary research goals included: accounts “for about 90 to 95 percent of all assessing how type 1 and type 2 diabetes dif- diagnosed cases of diabetes. It usually fer in children; learning about the possible begins as insulin resistance, a disorder in long-term health complications of diabetes in which the cells do not use insulin properly. children and adolescents; investigating how As the need for insulin rises, the pancreas children are being treated for diabetes; and gradually loses its ability to produce it.”55 determining the quality of life of diabetic chil- dren and adolescents.59 The American Diabetes Association describes type 2 diabetes as a “new epi- Initial results from the study show that demic” among American children.56 while type 1 diabetes remains the most Traditionally a disease of mature adults, common form of diabetes among children type 2 diabetes now accounts for 8 percent and adolescents, type 2 diabetes becomes to 45 percent of new pediatric diabetes more common after the age of 10, with cases, depending on geographical location.57 minority children more affected than non- Although there are a number of genetic risk Hispanic white children.60 A phase II study factors, obesity is largely driving the is underway and will wrap up in 2009. increase in childhood type 2 diabetes. The According to Francine Ratner Kaufman, problem is especially severe among chil- president of the American Diabetes dren and youth of African, Hispanic, Asian, Association, “there is no doubt that the or American Indian ancestry.58 emergence of this epidemic in children and In 2000, SEARCH for Diabetes in Youth, a 5- young adults is a major public health prob- year, $22 million research project funded by lem.”61 The association calls on schools CDC and the National Institute of Diabetes and communities to take an active role in and Digestive and Kidney Diseases (NIDDK), the prevention of type 2 diabetes in chil- was launched to identify the number of chil- dren by encouraging physical activity and dren under age 20 with diabetes by type, improved eating habits. age, sex, and race or ethnicity. SEARCH’s 25 I Heart Disease and Stroke mental health conditions than normal L People who are overweight are more like- weight adults.74 The odds of suffering ly to suffer from high blood pressure, high from any mood disorder rose by 56 per- levels of blood fats, and high LDL ("bad") cent among obese individuals (30 ≤ BMI ≤ cholesterol -- all risk factors for heart dis- 39.9) and doubled among the extremely ease and stroke.62 obese ( BMI ≥ 40).75 L Physically inactive people are twice as I Kidney Disease likely to develop coronary heart disease L Obese individuals (BMI ≥ 30) are 83 per- as regularly active people.63 cent more likely to develop kidney dis- L Heart disease is the leading cause of ease than normal weight individuals death in the United States, and stroke is (18.5<BMI<25), while overweight indi- the third leading cause.64 viduals (25< BMI≤30) are 40 percent L One in 4 Americans has some form of more likely to develop kidney disease.76 cardiovascular disease.65 L An estimated 24.2 percent of kidney dis- L Heart disease can lead to a heart attack, ease cases among U.S. men and 33.9 per- congestive heart failure, sudden cardiac cent of cases among women are related death, angina (chest pain), or abnormal to overweight and obesity.77 heart rhythm.66 I Arthritis L A stroke limits blood and oxygen to the brain and can cause paralysis or death.67 L Obesity is a known risk factor for the development and progression of knee L Roughly 30 percent of cases of hyperten- osteoarthritis and possibly osteoarthritis of sion may be attributable to obesity, and in other joints. For example, obese adults are men under the age of 45, the figure may up to 4 times more likely to develop knee be as high as 60 percent.68 osteoarthritis than normal weight adults.78 I Cancer L Among individuals who have received a L People who are overweight “may increase doctor’s diagnosis of arthritis, 68.8 per- the risk of developing several types of cent are overweight or obese.79 cancer, including cancers of the colon, L For every pound of body weight lost, esophagus, and kidney. Overweight is there is a 4-pound reduction in knee joint also linked with uterine and post- stress among overweight and obese peo- menopausal breast cancer in women.”69 ple with osteoarthritis of the knee.80 L Approximately 20 percent of cancer in I Obesity and Children’s Health women and 15 percent of cancer in men are attributable to obesity.70 L Nearly 32 percent of U.S. children and adolescents are overweight or obese (at or L Cancer is the second leading cause of above the 85th percentile of BMI for age).81 death in the United States.71 L Approximately 60 percent of obese children L It is unknown why being overweight can aged 5-10 years had at least one cardiovas- increase cancer risk. One theory is that cular disease (CVD) risk factor -- such as fat cells may affect overall cell growth in a elevated total cholesterol, triglycerides, person’s body.72 insulin, or blood pressure -- and 25 percent I Neurological and Psychiatric Diseases had 2 or more risk CVD risk factors.82 L Obesity may increase adults’ risk for L The American Academy of Pediatrics dementia. A review of 10 published stud- issued new guidelines in July 2008 recom- ies found that people who were obese at mending cholesterol screening of children the beginning of the studies were 80 per- as young as age 2 and adolescents with a cent more likely to later develop family history of high cholesterol or heart Alzheimer’s disease than those adults disease. The new guidelines also recom- who had a normal weight at enrollment.73 mend screening children whose family his- tory is unknown or those who have other L An analysis of data from a health survey factors for heart disease including obesity, of more than 40,000 Americans found high blood pressure, or diabetes.83 that obese adults were more likely to suf- fer from depression, anxiety and other 26 L Childhood weight problems can lead to L The number of fat cells a person has is complications such as elevated blood pres- determined by late adolescence; over- sure and cholesterol, joint problems, type weight and obese children can lose weight, 2 diabetes, gallbladder disease, asthma, but they do not lose the extra fat cells.86 depression and anxiety.84 L Young girls who are overweight or L Severely overweight and obese children obese suffer a variety of significant health often suffer from depression, anxiety dis- sequelae, including menstrual disturbances orders, isolation from their peers, low such as early onset menstruation, and are self-esteem, and eating disorders.85 more likely to suffer from polycystic ovary syndrome (PCOS).87 OBESITY AND PREGNANCY There is a growing body of evidence docu- treatment and hospital stays are more expen- menting the links between maternal health sive and complicated for pregnant women conditions, such as obesity and chronic dis- who are obese. CDC and Kaiser Permanente eases, and increased risks before, during, Northwest Center for Health Research found and after birth.88 in a recent study that obesity during pregnan- cy is associated with an increased use of Many pregnant women are overweight, health care services and longer hospital obese, or have diabetes, all of which can have stays.90 The study, which consisted of over negative effects on the fetus, as well as the 13,000 pregnancies, found that obese women mother. According to CDC, in 2002 approxi- required more outpatient medications, were mately 50 percent of women of child-bearing given more obstetrical ultrasounds, were less age (between 18 and 44) were either over- likely to see nurse midwives or nurse practi- weight or obese; 3 percent experienced high tioners in favor of physicians, and Cesarean blood pressure and 9 percent had diabetes.89 delivery rates were 45.2 percent for Not only are obesity and chronic diseases extremely obese women, compared with unsafe for the mother and the fetus, but 21.3 percent for women of normal weight.91 C. OBESITY AND PHYSICAL INACTIVITY U.S. GUIDELINES FOR PHYSICAL ACTIVITY Recommendations from the U.S. Recommendations from CDC93 Dietary Guidelines for Americans92 I Adults I Adults L Engage in a minimum of 30 minutes of L T reduce the risk of chronic disease, engage o moderate-intensity physical activity per in at least 30 minutes of moderate-intensity day (such as brisk walking) most days of physical activity on most days of the week. the week; or L To help manage body weight and prevent L Engage in a minimum of 20 minutes of unhealthy weight gain, engage in about 60 vigorous-intensity physical activity (such minutes of moderate-to vigorous-intensi- as jogging or running) 3 days a week ty activity on most days of the week. L Two days a week incorporate strength L To sustain weight loss, engage in at least training into routine such as weight lifting 60 to 90 minutes of daily moderate inten- to maintain and increase muscle strength sity physical activity. and endurance. L Include cardiovascular conditioning, I Children94 stretching, and resistance or calisthenics. L Children should engage in at least 60 min- I Children utes of moderate intensity physical activity L Engage in at least 60 minutes of physical most days of the week, preferably daily. activity daily. 27 TRENDS IN PHYSICAL ACTIVITY Adults: study published in the Journal of the I Currently, more than 22 percent of adult American Medical Association. However, by Americans say they do not engage in any age 15 years, adolescents were only engag- physical activity.95 ing in MVPA for 49 minutes per weekday and 35 minutes per weekend day.102 I More than half of adults report they do not participate in CDC’s recommended level of I Nationwide, 35 percent of high school stu- physical activity, which includes either 30 dents met the recommended levels of minutes or more of moderate physical physical activity, which is doing any kind of activity a day for 5 or more days per week, physical activity that increased their heart or 20 minutes or more of vigorous physical rate and made them breathe hard some of activity a day for 3 or more days per the time for a total of at least 60 minutes week.96 The minimum level of recom- per day on 5 or more days during the past mended activity is equivalent to walking 2 7 days before the survey.103 miles at a pace of 3 to 4 miles per hour.97 I Nearly 25 percent of high school students I Sixty percent of adults are not sufficiently did not participate in 60 or more minutes active to achieve health benefits.98 of any kind of physical activity that increased their heart rate and made them I Participating in leisure time physical activity breathe hard some of the time on any day declines as age increases.99 during the 7 days before the survey.104 I Women are less likely to engage in moder- I Only 54 percent of high school students had ate or vigorous physical activity.100 physical education class at least once a week; I African American and Hispanic adults are only 30 percent had daily physical education.105 less likely to be physically active than white I Nearly 25 percent of high school students adults.101 played video or computer games or used a computer for something other than school Youth: work for 3 or more hours per day on an I At age 9, children engaged in moderate-to- average school day.106 vigorous physical activity (MVPA) approxi- I 35 percent of high school students mately 3 hours per day on both weekends watched television 3 or more hours on an and weekdays, according to a July 2008 average school day.107 “EXERCISE IS MEDICINE” INITIATIVE “. . . (M)ore and more Americans will hear from a voice they trust that exercise is important, exercise is medicine. Indeed, exercise is not an option, but a necessary, active, direct way that people can maintain good health, avoid illness, improve the quality of their lives, reduce their health care costs and extend their life expectancy.” — Ronald Davis, M.D., president of the American Medical Association108 In November 2007, the American College of A few goals of the initiative include: Sports Medicine and the American Medical I Increase research and studies dedicated to Association came together in an effort to examining the effects of fitness and physi- increase physical activity among Americans. cal activity on health. The initiative, known as “Exercise is Medicine,” is centered on the theory of including exercise I Create a system whereby physicians are and physical activity as a prescription from able to refer patients to a “fitness special- physician to patient. Exercise and physical ist” and get reimbursed for their services. activity are considered integral parts of an I Educate physicians of all specialties about overall health plan, and are key components of screening patients for fitness and physical a health plan designed to prevent chronic dis- activity levels. eases and improve quality of life. 28 D. WEIGHT BIAS AND QUALITY OF LIFE A number of studies have reported an association between overweight and obesity and poor- er quality of life. According to a Yale University study, weight discrimination was reported by 7 percent of adults in 1995-1996, and that percentage rose to 12 percent in 2004-2006.109 Research has shown discrimination against people with obesity in several areas, including the hiring process, in the workplace, among medical professionals, and in educational institutions. I Weight Bias In Employment I Physical and Emotional Consequences L A 2007 study of more than 2800 adults of Weight Bias found that overweight adults were 12 L Research shows that obese youth who times more likely to report weight-based are victimized by peers because of their employment discrimination, obese persons weight are more likely to have suicidal were 37 times more likely, and severely thoughts and engage in suicidal obese adults were 100 times more likely.110 behaviors.118 L Compared with job applicants with the same L Overweight young people who are targets qualifications, obese applicants are rated more of weight teasing are more likely to negatively and are less likely to be hired.111 engage in unhealthy weight control and L Overweight people earn 1 percent to 6 binge eating, and they are less likely to percent less than non-overweight people participate in physical activity.119 in comparable positions.112 L In a study of more than 2,400 overweight and obese adults, 79 percent reported I Weight Bias in Health Care that they coped with weight bias by L Self-report studies show that doctors view eating more.120 obese patients as lazy, lacking in self-con- L Overweight and obese adults are more trol, non-compliant, unintelligent, weak- likely to avoid, cancel, or put off important willed, and dishonest.113 health appointments.121,122,123 L Sixty-nine percent of overweight people L Obese people report significantly greater report having been stigmatized by doctors.114 disability due to body pain than patients with other chronic medical conditions, I Weight Bias in Education with the exception of migraine sufferers.124 L Teachers view overweight students as untidy, L One study found that obese children were more emotional, less likely to succeed on 5-and-a-half times more likely to have a homework, and more likely to have family poor quality of life than their healthy problems. They also have lower expecta- counterparts. Severely obese children tions for overweight students.115,116 even had a slightly lower quality of life L Obese students are significantly less likely than children undergoing chemotherapy.125 to be accepted to college despite compa- rable academic records.117 29 E. NUTRITION: THE OTHER SIDE OF THE ENERGY BALANCE DIETARY NUTRITION GUIDELINES FOR AMERICANS126 I Key Recommendations L Consume 3 or more ounce-equivalents of L Consume a variety of nutrient-dense foods whole-grain products per day. At least half of and beverages within and among the basic grain intake should come from whole grains. food groups while picking foods that limit L Consume 3 cups per day of fat-free or the intake of saturated and trans fats, cho- low-fat milk or milk products. lesterol, added sugars, salt, and alcohol. L Increase dietary intake of calcium, potassium, L Eat more dark green vegetables, orange fiber, magnesium, and vitamins A, C, and E. vegetables, legumes, fruits, whole grains, and low-fat milk and milk products. I Specific Recommendations for L Eat less refined grains, total fats, added Children and Adolescents sugars, and calories. L At least half of grains consumed should be whole-grain. Children 2 to 8 years old I Specific Recommendations for should consume 2 cups per day of fat-free Adults or low-fat milk or milk products and chil- L Consume 2 cups of fruit and 2 1/2 cups dren 9 and up should drink 3 cups per day. of vegetables per day for a 2,000-calorie L Increase dietary intake of calcium, potassi- intake. um, fiber, magnesium, and vitamin E. 30 AMERICANS’ UNHEALTHY EATING HABITS Obesity is the result of a chronic energy imbalance: people who suffer from overweight and obesity consume more calories than they burn off in physical activity. Efforts to encourage people to change eating habits, however, are as complex as trying to motivate people to be more physically active. Healthy nutrition, as with physical activity, has a positive effect on people’s health no matter how much they weigh. According to an article published by the National Institute for Health Care Management, “for most Americans, a healthy diet means: smaller portions (fewer calo- ries, minimal saturated and ‘trans’ fats, few sweets and low fiber carbohydrates (think desserts and sodas), and more fruits and vegetables.”127 Instead, the American diet has skewed towards large portion sizes that are high in fat and calories. Some changes in the eating habits of Americans over the past few decades include: I More calories I More sugar L Adults consumed approximately 300 more L “Added sugar” consumption is nearly 3 calories daily in 2002 than they did in times the USDA recommended intake.134 1985.128 L Average consumption of added sugars L Women aged 20-74 consumed nearly 22 increased 22 percent from the early 1980s percent more calories in 1999-2000 than to 2000.135 they did in 1971-1974; men consumed nearly 7 percent more calories.129 I More dietary fat L Adolescent females aged 12-15 consumed L Americans consumed an average of 600 approximately 4 percent more calories in calories worth of added fats per person 1999-2000 than they did in 1971-1974; per day in 2000.136 16- to 19-year old females consumed approximately 15 percent more.130 I A drop in milk consumption and a large increase in soda and fruit juice I Bigger portion sizes consumption L A study in the Journal of the American L Milk consumption dropped 39 percent Medical Association examined the rise in from 1977 to 2001 for children aged 6-11 portion sizes and found that from 1977- while consumption of soda rose 137 per- 1998, portion sizes for selected popular cent, fruit juice rose 54 percent, and fruit food items and overall energy intake drink rose 69 percent.137,138 increased for foods purchased in restau- rants or fast food establishments and for I A major increase in eating out foods prepared in the home.131 L In 1975, approximately 25 percent of food spending was in restaurants; by 2004, this I Fewer fruits, vegetables, and whole figure had risen to 42 percent.139 grains L Spending in fast food restaurants grew L A 2003 USDA report examining American over 18 times (from $6 billion to $110 bil- food consumption patterns called lion) in the past 3 decades. America’s per capita fruit consumption L In 1970, there were approximately 30,000 “woefully low” and limited to a small fast-food restaurants in the United States.; range of fruit options, and that vegetable in 2001, there were approximately 222,000. consumption “tells the same story.”132 L Children ate out at fast-food and other L Per capita grain consumption has risen restaurants nearly 3 times more in 1996 nearly 50 percent since the early 1970s, than they did in 1977. but whole grain consumption has dropped.133 L In 2004, 63 percent of children aged 1-12 ate out at a restaurant 1-3 times per week.140 31 PORTION DISTORTION 20 YEARS AGO TODAY Coffee with whole milk and sugar Mocha with steamed milk and syrup 8-ounce serving size 16-ounce serving size 45 calories 350 calories Difference: 305 calories Muffin Muffin 1.5 ounce serving size 4 ounce serving size 210 calories 500 calories Difference: 290 calories Pepperoni Pizza Pepperoni Pizza 2 slices 2 slices 500 calories 850 calories Difference: 350 calories Chicken Caesar Salad Chicken Caesar Salad 1 1/2-cup serving size 3 1/2-cup serving size 390 calories 790 calories Difference: 400 Calories Popcorn Popcorn 5-cup serving size 11-cup serving size 270 calorie 630 calories Difference: 360 Calories Chicken Stir Fry Chicken Stir Fry 2-cup serving size 4 1/2 cup serving size 435 calories 865 calories Difference: 430 Calories Source: National Heart, Lung, and Blood Institute Obesity Initiative, Portion Distortion II Interactive Quiz. Accessed at: http://hp2010.nhlbihin.net/portion/index.htm FOOD COST AND PORTION SIZES A recent Washington Post article reported ed to come up with ideas to continue turning that many restaurants are trimming down a profit. One of the main ways restaurants portion sizes.141 While the change is intended are adjusting is by reducing portion sizes, to boost restaurants’ profits, there is poten- often times without decreasing the cost to tial that it also could have positive long-term the consumer. Restaurants are using various health outcomes. With an increase in gasoline “tricks” such as using smaller plates and and food costs and current public concern lighter forks to make the reduced portions over a potential recession, restaurants need- look and feel more like the old portion sizes. 32 THE ART OF SUPERSIZING In the mid-1960s David Wallerstein managed a them, he gave the idea a try -- thus creating chain of movie theaters in T exas and was con- the still successful Big Gulp.144 stantly trying to find a way to increase profits. Fast-food and restaurant customers have Wallerstein tried different ways -- 2-for-1 pop- come to associate huge quantities of food corn sales and other food and beverage combi- with value, a combination that leads to an nations -- but nothing worked. He eventually increase in caloric consumption per individual. realized that customers were reluctant to buy 2 A study at Pennsylvania State University found of anything because that would appear glutton- that consumers who were given a 50-percent ous.142 Then he decided to rethink portion sizes. larger pasta dish ate 43 percent more than Wallerstein took his theory to Ray Kroc, the those given a smaller portion.145 Another founder of McDonalds, and persuaded him to study reports that Americans are eating more serve bigger portions. After setting up video calories per day than they did in the 1970s.146 surveillance and watching customers, Kroc Some companies, such as McDonald’s and saw that although customers were reluctant Wendy’s, have eliminated their “Supersize” to order seconds, they were happy to keep and “Biggie” menus after criticism and negative eating. The result: Supersizing.143 Wallerstein publicity.147 But the question remains whether may have been one of the first to explore the dropping these menus choices affected any real economics of portion sizes, but he certainly change in the industry. A study by a professor wasn’t the only one to benefit. In the 1970s, and dietician at New York University found a Coca-Cola representative tried to sell the that Wendy’s original “Biggie” drink, containing idea of 32-ounce cups to 7-Eleven. Although 32 ounces, has been renamed simply as a Dennis Potts, a midlevel manager of 7-Eleven medium. A large now contains 42 ounces.148 at the time, thought people would never buy 33 F. ECONOMIC COSTS OF OBESITY HEALTH CARE COSTS I The total cost of obesity and physical I A 2007 study found that excessive weight inactivity in 2000 was estimated to be gain among employees is related to higher $117 billion.149 amounts of workers’ compensation claims.162 Obese workers had on average 11.65 claims I Obesity-related annual costs for children per 100 full-time employees, compared to more than tripled between 1979 and 1999.150 normal weight employees who had 5.8 I A 2008 study reported that obese employ- claims per 100-full time employees.163 ees cost private employers approximately I The cost of obese employee workers’ com- $45 billion a year as a result of medical pensation claims were also significantly high- expenses and excessive absenteeism.151 er. Obese employees had $51,091 in med- I Obesity has been linked to a 36 percent ical claims costs per 100 full-time employ- increase in healthcare spending, which is ees, compared to only $7,503 in medical presently more than smoking or drinking.152 claims costs for normal weight workers. And obese workers had $59,178 in indemni- I Higher health care costs for obese and ty claims costs per 100 full-time employees, sedentary workers signal poorer overall compared to only $5,396 in indemnity health among these individuals. And given claims costs for normal weight employees.164 poorer health, lower worker productivity and increased absenteeism are more likely Occupational Health and Safety Costs among obese and physically inactive employees. I The number of severely obese (BMI ≥ 40) patients quadrupled between 1986 Lower Worker Productivity and and 2000 from one in 200 to one in 50. Increased Absenteeism The number of super-obese (BMI ≥ 50) patients grew by a factor of 5, from one I Researchers found that obese workers had in 2,000 to one in 400.165 Emergency 183.63 lost workdays per 100 full-time responders and health care providers employees, compared to normal weight face unique challenges in transporting and workers who had 14.19 lost workdays per treating the heaviest patients. 100 full-time employees.153 I A typical ambulance outfitted with equip- I As people’s BMI increases so do the num- ment and 2 emergency medical technicians ber of sick days, medical claims and health (EMTs) that can transport a 400-pound care costs.154 patient costs $70,000. A specially outfit- I A 2004 study concluded that excessive ted bariatric ambulance that can transport weight and physical inactivity negatively patients weighing up to 1,000 pounds impact the quality of work performed, the costs $110,000.166 quantity of work performed and overall I A standard hospital bed can hold 500 job performance among obese, sedentary pounds and costs $1,000. A bariatric hos- individuals.155 pital bed that can hold up to 1,000 pounds costs $4,000.167 Higher Workers’ Compensation Claims I A number of studies have shown obese I Nearly one in 2 emergency medical tech- workers have higher workers’ compensation nicians sustained a back injury while per- claims.156, 157, 158, 159, 160, 161 forming EMS duties. Most blamed lifting extremely obese patients.168 34 G. THE HIGH PRICE OF FOOD USDA is predicting that food prices will rise tion programs, such as the Supplemental 4.5 percent during 2008 due to a world-wide Nutrition Assistance Program (SNAP) (formerly grain shortage, high energy costs, and a weak the Food Stamp Program) and Women, Infants U.S. dollar. Rising food prices are likely to have and Children (WIC) will continue through 2008 a negative impact on Americans’ eating habits, as a result of rising unemployment.176 The according to Carol Tucker Foreman, director number of Americans receiving food stamps is of the Consumer Federation of America. She projected to grow from 26.5 million in 2007 to says middle- and low-income families may be 27.8 million in 2008.177 Although food stamps simultaneously pushed towards hunger and provide needy Americans with a safety net, obesity. “They will be hard pressed to buy critics contend the program hasn’t kept up with fresh fruits and vegetables as prices rise. inflation, meaning that recipients are able to Instead, they will look to the cheapest foods buy fewer foods with their benefits. which aren’t necessarily the healthiest.”169 WIC is also facing rising demand coupled with There is little doubt that increases in the price increasing prices for food good. WIC provides of dairy goods, grains, and fresh fruits and veg- federal grants to states for supplemental foods, etables will lead consumers to scale back on health care referrals, and nutrition education costlier, healthy food.170 A 2007 study by for low-income pregnant, breastfeeding, and researchers at the University of Washington non-breastfeeding postpartum women, and to found that unhealthy, high-calorie foods cost an infants and children up to age 5 who are found average of $1.76 per 1,000 calories, while low- to be at nutritional risk.178 Unlike the food calorie, nutritious foods cost $18.16 per 1,000 stamps program, WIC is not an entitlement calories.171 The study also found that unhealthy, and Congress would have to approve an high-calorie foods are not only the least expen- increase in appropriations to avoid denying aid sive, but also most resistant to inflation.172 As to low-income mothers and children. University of Washington epidemiologist Adam Drewnowksi, one of the study’s co-authors, School Lunch Programs told The Philadelphia Inquirer, “fruits, vegeta- Schools across the country are also dealing bles, and fish are becoming luxury goods com- with rising food prices. The cost of staple pletely out of reach of many people. foods including, milk, grains, produce and Consumption of cheap food will only grow.”173 meat have risen over 23 percent.179 The Already, rising food costs have prompted Miami-Dade County Public School System changes at food banks and charities, govern- saw the price of milk rise an additional $4.5 ment social assistance programs, and schools. million in the 2007-2008 school year alone.180 Rising food prices have come at a time when Food Banks schools are also being asked to prepare The U.S. economic downturn has forced more healthier, lower-fat meals to help stem the Americans to seek food assistance. A top offi- tide of childhood obesity. In many cases, cial at America’s Second Harvest, the nation’s schools are being forced to cut back on more leading hunger-relief charity, told The expensive foods such as whole-grain breads Washington Post that requests for food assis- and fresh fruits and vegetables.181 According tance from April 2007 to April 2008 are up 30 to Kenneth Hecht, executive director of percent.174 The increased demand for food California Food Policy Advocates, a public assistance comes at a time when food contribu- policy organization dedicated to improving tions from farmers and grocery chains have the health of low-income Californians, schools declined. Farmers are both able to export are forced to cut back on the healthier, more more of their goods and sell certain cash crops, costly items because school boards do not such as corn and soybeans to domestic renew- want to lose money. “This insistence that able energy producers. Meanwhile, grocery food service stay in the black means that rev- chains have strengthened their inventory man- enues must be high,” he told the Committee agement leading to fewer surplus goods.175 The on Education and Labor of the U.S. House of pressure has gotten so bad that some charities Representatives, which held hearings on the are asking state and local governments for help. subject in March 2008.182 Without an increase in state or federal funding, he said schools will Federal Food Assistance Programs be forced to choose less healthy, less expen- According to the Congressional Budget Office, sive foods that they can sell for a profit, such double-digit growth in federal food and nutri- as sugary drinks or potato chips. 35 State Responsibilities and Policies 3 SECTION I n this section, TFAH examines trends in state legislative actions and poli- cies aimed at obesity reduction. This overview is intended to help inform and begin an evaluation of whether these efforts are having a positive impact. Each state identifies goals and strategies for This section provides an overview and update improving the health of its citizens. States to previous years’ analyses and includes: are undertaking a wide range of efforts to A. State Obesity Plans. address the obesity crisis. Since 2003, TFAH has been reviewing these state policies. For B. Survey of State Chronic Disease Directors this year’s report, TFAH produced a supple- and Directors of Health Promotion and ment to F as in Fat: How Obesity Policies Are Education. Failing in America entitled, Obesity-Related C. State Obesity-Related Legislation. Legislative Action in States, which provides greater detail about specific legislation. The D. Qualitative Evaluation of State Obesity- supplement is available on TFAH’s Web site, Related Legislation. www.healthyamericans.org. A. STATE OBESITY PLANS Over the past decade, the majority of states levels of influence -- individual, interperson- and D.C., have added overweight and obesi- al, organizational, community, and public ty to their list of important issues to policy.184 Many of the plans draw on guidance address.183 As a result, a growing number of from CDC to use policy and environmental states have published state plans that focus changes to target 6 specific behaviors: on physical activity and healthy nutrition. I Physical activity. Currently, 41 states have plans in place with specific strategies and goals to lower the I Fruit and vegetable intake. prevalence of overweight, obesity and obesi- I Breastfeeding. ty-related chronic diseases in each state. Virginia and D.C. have childhood obesity I Consumption of sugar-sweetened plans, and at least 7 more have drafts of beverages. plans in the works, which they expect to I Intake of high energy density foods. make available to the public over the next year or 2. (See Appendix B: Methodology I Television viewing. for State Obesity Plan Review.) Some states focus exclusively, or to a large Each state has a unique plan, but many pro- extent, on childhood obesity. Generally, states grams contain similar goals and means to have goals to improve childhood health achieve those goals. One objective common through decreasing the amount of time chil- to almost every state is the urgency to get dren spend in front of the TV and other elec- people involved on all levels; this is known as tronic entertainment devices, increasing phys- the Social-Ecological Model. This model aims ical activities available to all children, using to affect behavioral change by engaging all public schools to implement physical activity 37 and healthy nutrition programs, and encour- It is also important to include a system of aging communities to help raise healthier measurement to determine what the state children through local involvement. has accomplished, and to ensure that the state continues to work toward the plan’s While some states have more general goals goals. The majority of states have a surveil- of decreasing the percentage of overweight lance and evaluation section within their people in their state, others have set out plans to ensure that programs are moni- very specific goals. Utah, for instance, tored, and the programs correlate with the expects that by 2010 the percentage of chil- goals of the plan. One of the best ways to dren in that state who report being over- monitor and evaluate a plan is through pilot weight by 10 percent or more will decrease programs, which many of the states have from 12.3 percent to 10.8 percent.185 already instituted or intend to institute. Developing a plan to address the problem of While all the plans suggest programs and overweight and obesity is an important step in activities to improve health and nutrition, the process of implementing change, but it is 20 of the plans include current rates of over- certainly not the only step. In order to turn a weight or obesity within the state and also a plan into action, the state must secure the target percentage that should be reached by appropriate funding. Unfortunately, a major- a certain time. For example, one objective ity of the state plans do not address the issue of the Arkansas plan is to increase the per- of funding, or only briefly mention the need centage of children and adults who have a to secure funding. Many of the plans refer to healthy BMI. For adults, the goal is to go the need to secure resources for implementa- from 38 percent in 2003 to 42.1 percent in tion or suggest that local organizations apply 2010, and for children the goal is to go from for mini-grants, but beyond that there is no 60 percent to 65 percent.186 mention of how the plan will become a reali- ty. Fewer than 10 states include details regard- Publishing a nutrition and physical activity plan ing strategies for funding. New Mexico is one is just the first step of many that a state must of the few that includes a detailed description take. Implementation and follow-through are of how it intends to fund the plan by linking the next, and most important, steps. each objective to a funding source. 38 REVIEW OF STATE OBESITY PLANS — 2008 States Does the Does the Does the plan Does the Are the plan Does the Does the Does the plan Does the plan state have a plan involve specifically plan contain objectives plan link plan include include have a system strategic multiple assign roles & clear and related to funding to private sector provisions for evaluation plan to state responsibilities measurable reducing objectives? (business, regarding a and review? combat agencies? to state objectives? rates of industry) and healthier obesity? agencies? obesity? community state groups? workforce? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C.^ 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 42+DC 41+DC 29+DC 38+DC 25+DC 8+DC 41+DC 38+DC 28 Note: States with an * have a draft obesity plan in the works. States with an ^ have childhood obesity plans. 39 B. SURVEY OF CHRONIC DISEASE DIRECTORS AND DIRECTORS OF HEALTH PROMOTION AND EDUCATION In order to understand which obesity pre- In May 2008, the National Association of vention and reduction strategies experts Chronic Disease Directors (NACDD) and believe are most effective and important, the DHPE association distributed a survey TFAH conducted a survey of state Chronic by email to their members. The survey was Disease Directors (CDDs) and state administered through the Internet service Directors of Health Promotion and Survey Monkey (www.surveymonkey.com) Education (DHPEs). CDDs and DHPEs are and was available for a period of over 3 state government employees who serve on weeks. A total of 25 CDDs and DHPEs the front lines of public health in each state responded to the survey. There was a gen- by developing and implementing policies eral consensus between respondents with and programs to prevent chronic disease regards to barriers to solving the problem of and promote better health. obesity, as well as what direction they would like to see the new administration take. 1) STATE STRATEGIC PLANS TO COMBAT OBESITY Almost two-thirds (64.3 percent) of the In addition, respondents noted the follow- respondents reported that their state cur- ing limitations with implementing their rently has a strategic plan to combat obesity. state’s obesity plans: While this is a much needed and promising I 94 percent expressed frustration with step for states to take, the directors voiced a data limitations and problems with meas- few concerns associated with the plans, uring their programs’ outcomes. including: I 82 percent said that their state does not I Lack of resources to implement the have the necessary workforce to design, strategic plan. implement and evaluate physical activity, I Recent or anticipated loss of federal nutrition and obesity programs. funding. I 75 percent responded that their plans I Shortage of data to measure performance have no funding linked to their strategic outcomes of strategic plan. obesity plan. 2) BARRIERS TO SOLVING THE PROBLEM OF OBESITY What Are the 3 Major Barriers to Preventing and Treating Obesity In Your State? Lack of population health funding for health promotion and disease prevention 91.3% Lack of leadership on the issue (e.g., obesity is not a political priority, government funds not being allocated to the issue, etc.) 47.8% Lack of research and practice-based evidence to influence policies and programs. 43.5% Lack of skilled workforce to carry out implementation. 34.8% Unclear and inconsistent messages regarding nutrition and physical activity. 21.7% Lack of public awareness about severity of problem 21.7% 40 The CDDs and DHPEs reported the top 3 bar- I Lack of research and practice-based evi- riers to treating obesity in each state included: dence to influence policies and programs. I Lack of funding for health promotion Respondents also expressed concern about and disease prevention. lack of insurance coverage for obesity treat- ments, such as nutrition counseling. I Lack of leadership. 3) SUGGESTED PRIORITIES FOR THE NEXT ADMINISTRATION The 2008 presidential election presents a In addition to funding, CDDs and DHPEs unique opportunity for public health officials would like to see more evidence-based to communicate their priorities to the next research that shows the most effective strate- administration. TFAH asked the CDDs and gies for obesity reduction. Nearly half of the DHPEs for their recommendations for the respondents said that more research is next administration regarding one impor- needed on individual and community-level tant action the federal government should interventions, including policy changes. take to address adult and childhood obesity. Respondents identified 2 actions as crucial Overall many of the directors had similar for childhood obesity: ideas. The top 3 recommendations for I Increase physical activity opportunities, adults included: specifically during the school day. I Funding for all states to address obesity. I Improve nutrition in schools, homes, com- I Strengthen worksite wellness programs. munities, and in advertisements directed at children. I Work on environmental changes, specifi- cally improving the built environment. 4) FOCUS OF NIH OBESITY PREVENTION RESEARCH AGENDA TFAH asked CDDs and DHPEs what their at community, worksite and school-based top research question would be if they could approaches. determine the National Institute of Health’s I Do physical activity/physical education (NIH) research agenda for obesity. Again, requirements and high nutrition stan- many of the respondents emphasized the dards help students perform better in the need for more evidence-based strategies for classroom? If there is a connection preventing and treating obesity. In particu- between healthier school environments lar, respondents wanted NIH to focus on the and students’ academic performance this following questions: could bring together public health advo- I How can people maintain weight loss? cates and education advocates. Other than gastric surgery, what are the I What are the most effective ways to moti- most effective treatments for obesity? vate and encourage people to lead Given our very limited resources, can we healthy, active lives? What communica- identify the candidates for treatment that tion messages work? will have the best chance for success? I Is there evidence -- both in terms of I How do we translate research into practice? improved health and a return on invest- Instead of focusing on clinical approaches ment -- to support coverage of prevention to fighting obesity, researchers need to look services in benefits plans? 41 C. STATE OBESITY-RELATED LEGISLATION Since 2003, TFAH has tracked state obesity- state obesity-related legislation enacted related legislation in the following cate- between July 1, 2007 and June 30, 2008. gories: school nutrition, physical education, Additional details about the legislation can physical activity, and height and weight be found in the supplement to F as in Fat: measurements; tax policies; and litigation. How Obesity Policies Are Failing in America on This section provides an updated summary TFAH’s Web site. 1) SCHOOL-FOCUSED OBESITY LEGISLATION School-based programs have been shown to cally have discretion in deciding if they will have the potential to yield positive results in follow them, a principle known as local con- preventing and reducing obesity.187 Children trol. States often try to create incentives for spend large amounts of time at school and in following policies, such as attaching compli- before- and after-school programs, often ance rules to state funding. consuming as many as 2 meals and snacks in Emerging school-based efforts have focused these settings. on improving the quality of food sold in The more than 14,000 school districts in the schools, limiting sales of less nutritious foods, United States have primary jurisdiction for improving physical education and health setting local school policies. States can education, and encouraging increased physi- establish policies or pass legislation that cal activity either within the school day or affect schools, but the school districts typi- through extracurricular activities. 42 OBESITY-RELATED STANDARDS IN SCHOOLS -- 2008 Nutritional Nutritional Limited Physical BMI or Non-Invasive Health Receives Standards for Standards for Access to Education Health Screening for Education CDC School School Meals Competitive Competitive Requirements Information 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 18 25 27 50 + D.C. 19 2 48 + D.C. 22 Please Note: Checkmarks in chart above that are in red type represent new laws passed in 2007 or 2008. 43 SCHOOL LUNCHES I Eighteen states set nutritional stan- ing or serving any food item that has in any dards for school lunches, breakfasts, way been deep fried, par fried, or flash fried and snacks that are stricter than or sell or serve a food item containing artifi- existing USDA requirements -- cial trans fat (SB 132). Alabama, Arizona, Arkansas, California, I Colorado established the Child Nutrition Colorado, Connecticut, Kentucky, School Lunch Protection Program to Mississippi, Nevada, New Jersey, North ensure that each student in a Colorado Carolina, Oklahoma, Rhode Island, South public school has access to a healthy lunch Carolina, South Dakota, Tennessee, Texas at school. One objective includes increas- and Vermont. ing students’ consumption of whole grains, States that implemented new regulations fruits and vegetables, vitamins, calcium, between July 1, 2007, and June 30, 2008, protein, fiber, and iron; and reduce the include: consumption of sodium, cholesterol, sugar and calories (SB08-123). I California required as a condition to receiving funds from special grants for child I Tennessee required each local school nutrition in schools, commencing in 2007- board to submit to the commissioner a 2008 fiscal year, school districts and schools plan to require that availability of local shall be in compliance with USDA guidelines agriculture products (SB 3341). or the menu planning options of Shaping I Texas established a mandatory report Health as Partners in Education developed relating to reducing the amount of trans fat by the state (SHAPE California network) in schools (HB 4062). (SB 80 related bill) and prohibited from sell- SCHOOL MEAL NUTRITION GUIDELINES School meal nutrition standards do not panel of experts on child nutrition. In late reflect current nutrition science and, unfor- 2009, the IOM Committee on Nutrition tunately, are unlikely to be updated for Standards for School Lunch and Breakfast about 3 years. Since 1994, the Richard Programs is expected to provide USDA Russell National School Lunch Act has with recommendations for updating the required the school lunches to meet the school meal programs’ nutrition require- Dietary Guidelines for Americans (DGAs). ments. Once USDA receives the IOM rec- In 2004, the Child Nutrition and WIC ommendations, agency officials will then Reauthorization Act of 2004 (P 108-265) .L. seek to incorporate them into formal required the U.S. Secretary of Agriculture USDA guidance, which is expected to be to issue school nutrition guidelines that issued some time in 2010. A final rule will would ensure that American schoolchildren take even longer to be issued. This turn of consume foods recommended in the most events effectively postpones the update of recent DGAs. However, USDA has issued school meal nutrition standards by 5 years no proposed regulations in the 3 years beyond when they were due. Given the since the release of the 2005 DGAs.188 fact that school meal nutrition standards Instead, after deliberating internally for lack standards for sodium, trans fat, and those years, USDA was unable to come to whole grains, and that the fruit and veg- a consensus and contracted with the etable content is too low, this delay is of Institute of Medicine (IOM) to convene a considerable public health concern. 44 In the meantime, USDA is encouraging states Study (SNDA-III).190 SNDA-III is based on to gradually begin implementing 2005 DGAs data collected in the spring semester of the within school meal programs by:189 2004-2005 school year and provides a snap- shot of the school lunch and breakfast pro- I Increasing the amount and variety of grams. At the time, states primarily were whole-grain products. using the SMI to guide meal planning, I Increasing the availability of fruits and veg- although in the years since many state agen- etables and ensuring that school meals cies and schools have established nutrition offer both a fruit and a vegetable. policies that exceed SMI guidelines as they seek to address concerns about the child- I Offering only skim or 1 percent low-fat hood obesity epidemic. SNDA-III found: milk in schools. I More than two-thirds of school lunch pro- I Reducing sodium content in all meals. grams offered and served lunches that met I Providing fiber at levels that reflect the SMI standards for protein, vitamins, and DGAs. minerals, while only 20 percent of schools offered and served lunches that met SMI I Cutting cholesterol levels in meals so that standards for fat. over a week students consume less than 100 mg of cholesterol at lunch and less I Ninety-three percent of elementary than 75 mg at breakfast. schools and 86 percent of secondary schools offered students the choice of a I Minimizing the use of trans fats. low-fat lunch. Until USDA releases new guidelines incorpo- I More than half of the schools (58 percent) rating the DGAs into school lunch menu plan- offered students some type of fresh fruit ning, states are relying on the School Meals and/or raw vegetable every day. Initiative for Healthy Children (SMI), which requires schools to offer meals that provide no I Eighty-three percent of schools offered more than 30 percent of total calories from fat low-fat, one percent milk. and less than 10 percent from saturated fat. I Less than one-third of schools (30 per- The SMI also requires school lunches to pro- cent) used nutrient-based standards for vide adequate levels of certain nutrients. school meals, a system that ensures meals In 2007, USDA published findings from its meet age- and grade-appropriate nutrition third School Nutrition Dietary Assessment standards. 45 COMPETITIVE FOODS Competitive foods are defined as foods sold education agency that has adopted and at the same time as National School Lunch implemented the Pennsylvania Department Program foods are available.191 These foods of Education’s Nutrition Standards for are sold in vending machines, a la carte lines, Competitive Foods.192 The standards apply and school stores. to food, snacks, and beverages sold a la carte, in vending machines, at fundraisers, at I Twenty-five states have nutritional stan- school stores, and those served in classroom dards for competitive foods sold ala parties and holiday celebrations. (H.B. 842). carte, in vending machines, in school stores, or in school bake sales -- Alabama, I Twenty-seven states limit when and Arizona, Arkansas, California, Connecticut, where competitive foods may be sold Hawaii, Illinois, Indiana, Kentucky, Louisiana, beyond federal requirements -- Alabama, Maine, Maryland, Mississippi, Nevada, New Arizona, Arkansas, California, Colorado, Jersey, New Mexico, North Carolina, Connecticut, Florida, Georgia, Hawaii, Oklahoma, Oregon, Pennsylvania, Rhode Illinois, Indiana, Kentucky, Louisiana, Maine, Island, South Carolina, Tennessee, Texas, and Maryland, Mississippi, Nebraska, Nevada, West Virginia. New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, South States that implemented new regulations Carolina, Texas, and West Virginia. between July 1, 2007, and June 30, 2008, include: States that implemented new regulations between July 1, 2007, and June 30, 2008, I California Commencing July 1, 2009, include: schools or school district are prohibited, through a vending machine or school food I California law mandates that as of July 1, service establishment during school hours 2009, schools or school district are prohibited, and up to 1/2 hour before and after school through a vending machine or school food hours, from making available to elementary service establishment during school hours and or middle school pupils a food containing up to 1/2 hour before and after school hours, artificial trans fat and would prohibit the use from making available to elementary or mid- of artificial trans fat in the preparation of a dle school pupils a food containing artificial food item served to those pupils (SB 490). trans fat and would prohibit the use of artificial trans fat in the preparation of a food item I North Carolina sets forth a wellness pilot served to those pupils (SB 490). for state employees as well as directs the Board of Education to establish statewide I Oregon law requires that all food and bev- nutrition standards for school meals, a la erage items sold in public K-12 grade schools carte foods and beverages, and items served must at minimum meet nutrition standards. in the After School Snack Program adminis- Those standards apply to food and beverage tered by the Department of Public items sold in a school at all times during the Instruction and child nutrition programs of regular or extended school day when the local school administrative units. The nutri- activities in the school are primarily under tion standards will promote gradual changes the control of the school district board. This to increase fruits and vegetables, increase includes, but is not limited to, the time whole grain products, and decrease foods before or after classes are in session and the high in total fat, trans fat, saturated fat, and time when the school is being used for activi- sugar. To start in elementary schools fol- ties such as clubs, yearbook, band or choir lowed by middle and high schools (HB practice, student government, drama 1473). rehearsals or child care programs. The stan- dards required by this section do not apply I Oregon provides restrictions on the nutri- to food and beverage items sold in a school tional content and caloric load of certain foods at times when the school is being used for and beverages sold in schools during specified school-related events or nonschool-related times of school operation (HB 2650). events for which parents and other adults I Pennsylvania directs the Department of are a significant part of an audience or are Education to establish a School Nutrition selling food or beverage items before, during Incentive Program. The program shall pro- or after the event, such as a sporting event vide a supplemental school lunch and break- or another interscholastic activity, a play or a fast reimbursement to any school in a local band or choir concert (HB 2650). 46 CONCERNS ABOUT COMPETITIVE FOODS IN SCHOOLS Competitive foods are defined as foods sold at the same Office (GAO) found that 9 out of every 10 public schools in time as National School Lunch Program foods are available.193 the United States offered competitive foods to their stu- These foods are sold in vending machines, a la carte lines, dents, and almost 30 percent of public high schools earned and school stores. Although competitive foods sometimes more than $125,000 from competitive food sales.200 include fruits and vegetables, more often than not they are A 2007 review of school nutrition policies regarding com- high in fat, sugar, and salt, which increases the likelihood of petitive foods by the Center for Science in the Public over-consumption of calories and unhealthy weight gain.194 Interest (CSPI) found that while states have been strength- According to USDA’s School Nutrition Dietary Assessment ening their school nutrition policies over the past 10 years, Study III (SNDA-III), the prevalence of competitive foods is “results show that the changes occurring at the state level, widespread. Approximately one-third of elementary schools while positive, are fragmented, incremental, and not hap- and close to two-thirds of middle and high schools had foods pening quickly enough to reach all schools in a timely or beverages other than milk for sale through vending way.”201 The report noted that while USDA sets detailed machines, a la carte, and/or school stores during the lunch nutrition standards for federally subsidized school lunches, period.195 Vending machines, which are often stocked with USDA’s policy for competitive foods is “woefully out of chips, candy, and cookies, were available to students in more date.” In fact, although USDA can regulate the quality and than 80 percent of middle schools and 97 percent of high kinds of food sold in school cafeterias during lunch hours, it schools.196 A separate study published in the journal Pediatrics does not have the authority to regulate foods sold either found that food items sold a la carte were found in 71 percent outside of the cafeteria or outside of meal times, such as of elementary schools, 92 percent of middle schools, and 93 food sold in school stores, vending machines, fundraisers, percent of high schools. Of these schools, almost 80 percent etc. Congress would need to pass a law to allow USDA to provided unhealthy food items in their a la carte options.197 set nutrient standards for items sold outside of the cafeteria in schools. However, USDA has full authority to update its In addition to the diet-related health risks, USDA has highlight- nutrition standards for foods sold in the cafeteria outside of ed a number of other concerns related to competitive foods198: school meals (e.g., through the a la carte line), and since I Impact on school meal programs: The increase in USDA has not updated this standard since 1979 it is competitive food sales and accompanying decrease in stu- extremely out of date from a nutrition science perspective. dent participation in the National School Lunch Program A 2007 IOM report, Nutrition Standards for Foods in have implications for the overall viability of the program. Schools, does provides nutrition standards for competitive Declining participation results in decreased cash and com- foods, both those sold in vending machines and in the cafete- modity support from USDA for school meals. The reduc- ria a la carte lines. The report states that while federal school tion in federal funds may also contribute to less interest meal programs should be the primary source of foods and on the part of schools in maintaining quality school meal beverages at schools, if competitive foods are available, they programs that meet set nutritional standards, undermin- should “consist of nutritious fruits, vegetables, whole grains, ing the substantial federal investment in programs to pro- and nonfat or low-fat milk and dairy products.”202 vide healthy meals to children. Proceeds from competitive food sales are often used to pay I Stigmatization of school meal programs: USDA has for special activities or items not covered by the school’s expressed concern that the National School Lunch budget. As a result, there have been a number of challenges Program is often viewed as just for low-income children when local schools or parent-teacher associations have rather than being available to all children. Often, affluent sought to make sure only healthy foods are sold in schools. children spend their lunch money on items from vending The biggest challenge results from the fear of decreased machines and a la carte lines; these foods and beverages revenue from competitive foods sold a la carte, in vending tend to be more expensive than the school meal. machines, and in school stores creating a financial hardship I A mixed message: When children are taught in the for the school.203 classroom about good nutrition but are surrounded by A 2008 review of the literature, however, found that school vending machines, snack bars, school stores, and a la districts’ fears about lost revenues due to changes in com- carte foods of poor nutritional quality, they receive the petitive food offerings were unfounded. In fact, in some message that good nutrition does not actually matter and schools, there was increased student participation in the is therefore not important.199 school lunch program -- both from students paying full price Despite the low nutritional value of competitive foods, many for meals and from students receiving free or partially subsi- schools sell these products to gain much needed revenue. dized meals -- which may have compensated for any rev- A 2005 report by the U.S. Government Accountability enue losses in snack sales.204 47 PHYSICAL EDUCATION AND HEALTH EDUCATION IN SCHOOLS The 2005 IOM report Preventing Childhood new provision will require school systems Obesity: Health in the Balance recommend- to periodically review the waivers put into ed that state and local education authorities place, as opposed to allowing them to con- and schools should ensure that all children tinue without review (HB 1839). and youth participate in a minimum of 30 I Louisiana implemented the position of a minutes of moderate to vigorous physical health and physical education coordinator by activity during the school day.205 the Department of Education (Act No.180). I Every state has some form of require- I Maryland established a task force on student ments for physical education for students, physical fitness in State Public Schools (SB however, these requirements are often limited 955). Also now requires county boards of or not enforced and many of the programs education to ensure that students with disabili- are inadequate with respect to quality. ties have opportunities in specified physical States that implemented new regulations education and athletic programs (HB 1411). between July 1, 2007, and June 30, 2008, I Oklahoma increased P requirement in .E. include: elementary schools from 60 minutes to I Arkansas added K-6th grade physical activ- 120 minutes each week, beginning with ity set at a) 60 minutes per week of physical 2008-2009 school year (SB 1186). education and b) 90 minutes of physical I Oregon every public school student in activity per week, which may include daily kindergarten through grade 8 shall participate recess and/or physical education instruction. in physical education for the entire school Grades 5-8 requires 60 minutes of physical year. Students in kindergarten through grade education with no added requirement for 5 shall participate in physical education for at physical activity; and for 9-12 grades, 1/2 least 150 minutes during each school week. unit of physical education is required for Students in grades 6 through 8 shall partici- graduation (HB1039). pate in physical education for at least 225 I California clarified that a pupil may be minutes during each school week (HB 3141). granted exemption from courses in physi- I Texas students below sixth grade are cal education if the pupil has met at least 5 required to participate in moderate or vigor- of the 6 standards of the physical perform- ous daily physical activity for at least 30 min- ance test (SB 602). utes throughout the school year as part of I Colorado included the addition of school the district’s physical education curriculum or district wellness programs (HB 08-1224). through structured activity during recess. Beginning with the 2008-09 school year, stu- I Florida mandated 30 minutes of physical dents in grades 6 through 8 will be required education per day for grades 6-8 (changed to participate in daily physical activity for at from encouraged). Each district board shall least 30 minutes for at least four semesters provide 150 minutes of physical education during those grade levels (SB 530). each week for students in grades K-5 (SB 608). Also updated the contents of a school I Virginia required local school boards to pro- district’s written physical education policy to vide a physical fitness program with a goal of add details concerning the benefits of physi- 150 minutes per week for all students (HB cal education, and the availability of one-on- 242). one counseling concerning such benefits. I West Virginia implemented a wellness Provides for the conduction of at least 30 policy that states that school and district consecutive minutes of physical education processes should include a focus on devel- for students in K-6 and requires a one class oping ethical and responsible character, period per day of physical education for one personal dispositions that promote person- semester for students in grades 6 through 8. al wellness through planned daily physical Also provides waivers (SB 610). activity and healthy eating habits consistent I Illinois law provided that an approved with high nutritional guidelines (SB 595). waiver or modification to a physical educa- I Only 2 states -- Colorado and tion mandate remain in effect for no longer Oklahoma -- do not require schools to than two school years. The waiver can be provide health education. renewed, but no more than twice. The 48 PHYSICAL EDUCATION AND ADULT BMI A 2008 study by researchers at the Johns Hopkins I 2 percent of high schools required P daily for entire .E. Bloomberg School of Public Health found that high school year; students who participate in physical education 5 days a week I 7 percent of high schools required P daily for half a .E. are 28 percent less likely to become overweight as adults.206 year; The Institute of Medicine, the U.S. Department of Health I 3 percent of high schools required P for 3 days per .E. and Human Services, and the American Academy of week for entire year; and Pediatrics all recommend that students in all grade levels engage in daily physical education.207,208,209 The reality, howev- I 9 percent of high schools required P for 3 days per .E. er, is that only 54 percent of high school students attended week for half a year. PE classes in an average week when they were in school and The National Association for Sport and Physical Education only 30 percent attended P classes daily. In addition, par- .E. (NASPE) recommends that schools provide 150 minutes of ticipation in P class declines as students grow older, .E. instruction of physical education for elementary school chil- although the reason for the decline is more likely related to dren, and 225 minutes for middle and high school students school curriculum requirements.210,211 According to the 2006 per week for the entire school year.213 School Health Policies and Programs study212: PHYSICAL EDUCATION AND ACADEMIC ACHIEVEMENT The positive effects of physical activity on brain function are I A 2006 study analyzed data from nearly 12,000 teens across well documented with a number of studies showing that the United States to examine the relationship between phys- aerobic activity improves cognition and performance.214 ical activity and academic performance. Adolescents who Moderate and vigorous exercise increases the flow of blood reported either participating in school activities such as P.E. to the brain, which has a stimulating effect.215 Researchers and team sports, or playing sports with their parents, were speculate that this in turn makes schoolchildren more likely 20 percent more likely than those teens who did not engage to pay attention in class during the school day than children in physical activity to earn an “A” in math or English.222 who do not get any physical activity.216 And, in fact, there is There is also ample evidence that daily physical education a growing body of evidence that suggests physical activity is does not adversely affect academic performance. Many related to academic achievement.217 school systems have eliminated P or severely curtailed its .E. Of 14 published studies investigating the link between par- offering to focus on core academic subjects that students are ticipation in physical activity and academic performance, 11 tested on as part of the No Child Left Behind Act; this is found that regular participation in physical activity is associ- based on the assumption that sacrificing P will give students .E. ated with improved academic performance.218 and teachers more time to prepare for standardized tests and thereby boost the schools’ scores on those tests. But in fact, The following are some highlights from recent research on a number of studies show that students who spend time in physical activity, physical education, and academic performance: P or other school-based physical activities increased or .E. I A 2008 study by researchers at CDC found that higher maintained their grades and scores on standardized tests even levels of physical education in school were associated though they received less classroom time.223 A 2006 study of with an academic benefit among girls.219 There was, how- sixth graders found that students enrolled in P had similar .E. ever, no association between the 2 for boys. Similar grades and standardized test scores as students who were results were reported in a 1996 study of French-speaking not enrolled in P despite receiving nearly an hour less of .E., Canadian schoolchildren.220 Some have suggested that daily classroom instruction on core academic subjects.224 schoolgirls are less physically active than schoolboys and thus are more affected by the increase in physical activity. The fact that investigators have concluded that, at the very least, extra time spent in P does not hurt academic .E. I A 2007 study found that children who performed well on achievement is significant. Researchers are hopeful that this 2 measures of physical fitness tended to score higher on finding may persuade some school districts that reinstating state reading and math exams, regardless of gender or P classes need not come at the expense of their pupils’ .E. socioeconomic status.221 academic performance. 49 STUDENT HEALTH SCREENINGS I Seventeen states have passed Body Mass Index (BMI) commissioner of Health with any information for purposes screening requirements in schools OR legislation of an obesity report (SB2108). requiring weight-related assessments other than BMI. I Rhode Island enacted a new law that establishes the L States with BMI screening requirements: Arkansas, state’s healthy weight pilot program to be implemented in California, Florida, Illinois, Maine, Missouri, New York, several cities and towns. The program will incorporate a Pennsylvania, Tennessee, and West Virginia. combination of physical activity and nutrition plans that aim to encourage healthy weight and weight management in L States with weight-related screening requirements: children. Funding for the program will come from federal Delaware, Iowa, Louisiana, Massachusetts, Rhode Island, grants, funds allocated to the state for the purpose of com- South Carolina, and Texas. bating obesity and other sources deemed appropriate by States that implemented new restrictions between July 1, the legislature (HB 5900). 2007 and June 30, 2008 include: I Texas passed new legislation that says school districts must I New York passed new legislation that addresses BMI assess the physical fitness levels of all students in grades 3 assessment through health certificates in schools as directed through 12 (SB 530). by Commissioner of Health. Parents may refuse to be I Two states have enacted legislation requiring screening included in the survey. Each school district shall provide students for risk of type 2 diabetes -- California and Illinois. WEST VIRGINIA’S CARDIAC PROJECT The Coronary Artery Risk Detection in Appalachian includes nutrition and physical activity recommendations for Communities (CARDIAC) Project was launched 10 years ago children and families.225 in an effort to combat high levels of cardiovascular disease According to recent data from the project, the intervention is that afflict West Virginians -- adults and children -- in large working. In the 2006-2007 school year, 27.7 percent of fifth numbers. The school-based prevention program started out graders were obese based on BMI screening. That number in 3 counties in West Virginia and has since expanded to all of dropped to 25.8 percent in the 2007-2008 school year.226 Children the state’s 55 counties. In addition to providing health in other grades experienced declines in overweight and obesity as screenings to elementary school children across the state, the well, with the percentage of obese kindergartners falling from 20 CARDIAC Project mails a comprehensive health report to the percent to 17 percent. Among second-graders, the percentage of children’s families. The detailed report not only contains overweight students dropped from 19 percent to 15 percent.227 information on how to interpret the screening results, but PHILADELPHIA’S SCHOOL-BASED OBESITY PREVENTION INTERVENTION A May 2008 article in Pediatrics, reported the results of a meet the Dietary Guidelines for Americans. The program used school-based intervention at 5 elementary schools in inner-city social marketing to increase the consumption of healthy foods Philadelphia. The School Nutrition Policy Initiative focused on and promote active lifestyles. Finally, the program included a the prevention of overweight and obesity among children in family outreach component to encourage parents and students grades 4 though 6 over a 2-year period. The program includ- to purchase healthy snacks, limit TV viewing and be more active. ed 5 components: School self-assessment; nutrition education; At the start of the program, about 40 percent of the 1,349 stu- nutrition policy; social marketing; and parent outreach.228 dents in grades 4 through 6 were overweight or obese. Over The school self-assessment looked at environmental issues and the course of the 2-year program, there was a 50 percent focused on developing an action plan for change. Among the reduction in the number of children who became overweight. recommendations: Limit the use of food as a reward; limit the In the control schools, 15 percent of the children became over- use of unhealthy food for fundraising (e.g., bake sales); promote weight compared to 7.5 percent in the intervention schools. active recess; and serve breakfast in classrooms. School staff There were no differences observed in the number of children received approximately 10 hours of training in nutrition educa- who were obese. This, coupled with the fact that 7.5 percent tion in order to enable them to provide 50 hours of food and of students in the intervention schools still became overweight nutrition education per school year. School food service pro- suggests that stronger programs may be needed. grams removed all sodas, sugary drinks, and snacks that did not 50 2) COMMUNITY-FOCUSED OBESITY LEGISLATION States have also enacted obesity-related legislation aimed at the general population. These actions include tax policies, litigation restrictions, and planning and transportation policies. OBESITY RELATED STATE INITIATIVES -- 2008 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. 23 3 24 51 SNACK TAXES One way many states have tried to mitigate always use the revenues to combat obesity. the obesity epidemic is by taxing junk foods Instead, snack tax revenues are used to fund a in an attempt to reduce people’s consump- wide variety of state activities. tion of these products. Despite these problems, a growing number Seventeen states and D.C. currently have of Americans support the idea of taxing laws that tax foods of low nutritional unhealthy foods as a means to combat obesi- value:229 Arkansas, California, D.C., Illinois, ty and promote healthy nutrition. According Indiana, Kentucky, Maine, Minnesota, Missouri, to researchers at Yale University’s Rudd New Jersey, New York, North Dakota, Rhode Center for Food Policy and Obesity, the Island, Tennessee, Texas, Virginia, Washington, number of Americans who support taxing and West Virginia. unhealthy foods to subsidize healthy foods has risen from 33 percent in 2001 to 40 per- These taxes, also known as “Twinkie Taxes,” cent in 2003 and 54 percent in 2004.232 and “fat taxes,” are highly controversial. While proponents of the taxes argue that a tax Researchers at Yale University report that on junk food could be used to fund a healthy national junk food taxes could generate over eating and nutrition information campaign, $1.8 billion per year from the following items: opponents cite several problems.230 First, as I A 1-cent per 12-ounce soft drink tax health economist Eric A. Finkelstein notes, would generate $1.5 billion per year. these taxes penalize the poor “because people on lower incomes spend a higher proportion I A 1-cent per pound of candy tax would of their income on food, [therefore] this type generate $70 million per year. of tax is largely regressive in nature.”231 In I The proposed potato chip tax would gen- addition, the amount of taxes levied on junk erate $54 million per year. foods is so small that it is unlikely to serve as a deterrent to people. Finally, many states that I Proposed taxes on other snack foods, fats and have passed a version of a snack tax do not oils would generate $190 million per year.233 ELIMINATING TAXES ON HEALTHY FOODS In addition to looking at imposing a snack shown are 10 times as expensive as tax on unhealthy foods, the Mississippi unhealthy, high-calorie foods -- more Health Advocacy Program, has argued that affordable.235 Second, by eliminating the states such as Mississippi, which have exist- tax only on healthy foods, the state of ing grocery taxes for all food items, should Mississippi would continue to receive rev- remove the tax on healthy foods.234 enues from the purchase of unhealthy Mississippi is currently one of 5 states that foods. The main challenge facing legisla- taxes foods purchased for home consump- tors and policy makers who may want to tion. The group argues that eliminating consider this approach is how to define the 7 percent sales tax on healthy foods, “healthy foods.” The Mississippi Health while maintaining the tax on junk foods Advocacy Program recommends convening would achieve 2 goals. First, it would a panel of nutritionists and dieticians to make healthy foods -- which studies have define healthy foods. 52 MENU LABELING Menu labeling -- the posting of nutrition infor- ered menu labeling legislation include: Arizona, mation on menus and menu boards -- is a poli- California, Connecticut, D.C. Hawaii, Illinois, cy that more states and localities are consider- Iowa, Kentucky, Maine, Massachusetts, ing each year. Supporters of nutrition labeling Michigan, New Jersey, New Mexico, New at fast-food and chain restaurants, including York, Pennsylvania, Tennessee, Vermont and the American Medical Association, want label- Washington.239 In California, menu-labeling leg- ing that is easy to understand and which islation passed both chambers of the state leg- includes the total calories, fat, saturated fat, islature but was vetoed by Gov. Arnold trans fat and sodium content of menu items.236 Schwarzenegger (R) on Oct. 14, 2007.240 Supporters are considering reintroducing a Seventeen states and Puerto Rico, as well as menu-labeling bill in 2008. At the local level, numerous local governments, introduced legis- Seattle, New York City and San Francisco have lation either in 2007 or 2008 to require restau- menu-labeling provisions in place; 5 other rants to post nutrition information alongside localities have legislation pending.241 their menu items.237,238 The states that consid- Voluntary Efforts Instead of mandated menu labeling, some states milligrams of sodium.242 T date, Subway, o have chosen to focus on voluntary menu labeling McDonald’s, Outback Steakhouse, and Macayo’s programs. In Arizona, the Department of Mexican Kitchen have signed onto the program. Health Services launched the Smart Choice Critics of these voluntary programs highlight a Program after the legislature rejected a bill that number of problems. First, many restaurants would have required restaurants to post nutri- choose not to participate in these programs. tional information on menus. Under the Smart Second, the nutrition information is not easily Choice Program the state works with participat- accessible. Instead of posting the calorie and fat ing restaurants to evaluate and, if necessary, counts on the menu, most restaurants choose to modify menu items to meet specific nutrition cri- print up brochures which may be hard to find, or teria. A main dish, for example, should have the they post the information on the Internet. While following: A minimum of 2 servings of beans, having the information available online is useful, it whole grains, fruits, or vegetables; no more than does not help the customer who is waiting to 700 calories; no more than 30 percent of total place an order in the restaurant. Finally, the calories from fat; no more than 15 percent of nutrition information in these brochures can be total calories from saturated fat; no more than difficult for the average consumer to use.243 0.5 percent of trans fat; and no more than 1,500 LEGISLATION TO LIMIT OBESITY LIABILITY Many states have responded to the obesity Proponents of these bills argue that the epidemic by passing laws that prevent individ- central issue is “common sense and personal uals from suing restaurants, manufacturers, responsibility.”244 Passage of these bill indicates and marketers for contributing to unhealthy a level of support for the view that obesity is weight and related health problems. These an individual health issue. Supporters also laws that limit liability are fairly controversial, endorse a 2004 White House statement that and have been prompted by fears of obesity “food manufacturers and sellers should not be lawsuits similar to tobacco lawsuits. However, held liable for injury because of a person’s they are one of the most visible obesity-relat- consumption of legal, unadulterated food and ed policies to emerge in recent years. a person’s weight gain or obesity.”245 Twenty-four states have passed obesity Opponents of limited liability laws support liability laws: Arizona, Colorado, Florida, the position that “it’s impossible for con- Georgia, Idaho, Illinois, Indiana, Louisiana, sumers to exercise personal responsibility Kansas, Kentucky, Maine, Michigan, Missouri, when businesses are concealing important New Hampshire, North Dakota, Ohio, information about their products,” such as Oregon, South Dakota, Texas, Tennessee, the number of calories in restaurant food or Utah, Washington, Wisconsin and Wyoming. the lack of consistency in food labeling.246 53 LAND USE, URBAN PLANNING AND TRANSPORTATION POLICIES Health officials and elected leaders are increasingly aware of the and transportation policy and plans.247 However, the bulk of this importance that communities have on the health of their resi- type of legislative action has been at the state and local level. dents. At the federal level, Senator Barack Obama (D-IL) and TFAH’s F as in Fat: How Obesity Policies Are Failing in America Representative Hilda Solis (D-CA) have introduced legislation 2005 report included a state-by-state review of green space, that would require the CDC director to develop guidance for brownfields, and sprawl initiatives (available online at the assessment of potential health effects of land use, housing, www.healthyamericans.org). Sprawl describes spread-out areas where homes may be iso- the government. Green spaces provide communities with lated from schools, the workplace, and other frequent destina- opportunities for recreation and physical activity by provid- tions. As a result, people “who live in these areas may find that ing areas for walking, biking, and other sports.249 driving is the most convenient way to get everything done, and Brownfields are former commercial and industrial sites, many they are less likely to have easy opportunities to walk, bicycle, of which are abandoned or contaminated with hazardous sub- or take transit as part of their daily routine.”248 stances or pollutants. Often, these locations provide no usable Green spaces describe open, undeveloped recreational space for the surrounding area and remain as decaying eye- spaces that are accessible to the public and maintained by sores, environmental health threats, and indicators of blight. COMPLETE STREETS INITIATIVES Physical inactivity, coupled with unhealthy eating habits, is a The National Complete Streets Coalition is focusing on the major driver of the current obesity epidemic. More than half first 2 policy options by working with state, county and of the U.S. adult population does not meet the recommended city governments to incorporate features that promote daily physical activity guidelines, while a quarter of U.S. adults regular walking, cycling and transit use into just about report being completely inactive.250 (See Section 2: Fast Facts every street. To date, more than 75 states, counties, for recommended daily physical activity guidelines.) regional governments and cities have complete streets policies, according to the Coalition. A complete streets One major obstacle to physical activity is concern about safe- policy enables all users -- pedestrians, bicyclists, motorists, ty. For example, the number of children walking to and from and bus riders of all ages and abilities -- to safely move school has declined dramatically over the past 40 years, from along and across a complete street. 48 percent of students in 1969 to 16 percent of students in 2001.251 Parents frequently list traffic safety concerns as a top While the bulk of the 2-year old coalition’s efforts have reason that their children do not walk or bike to school.252 focused on state and local governments, the coalition has also pushed for federal action on the issue. In March 2008, Sens. Governments and communities that address traffic safety con- Tom Harkin (D-IA) and Thomas Carper (D-DE) introduced cerns can promote healthier living. For instance, a 2003 study the Complete Streets Act (S.2686). In May 2008, Rep. found that 43 percent of people with safe places to walk within Doris Matsui (D-CA) introduced the Safe and Complete 10 minutes of home met recommended activity levels; among Streets Act of 2008 in the House (H.R. 5951). The bills those without safe places to walk just 27 percent met the rec- ensure that “all users of the transportation system, including ommendation.253 An Australian study found that residents are 65 pedestrians, bicyclists, and transit users as well as children, percent more likely to walk in a neighborhood with sidewalks.254 older individuals, and individuals with disabilities, are able to A review by the National Conference of State Legislatures travel safely and conveniently on streets and highways.”256 identified 5 state policy options that are most effective at Two members of the National Complete Streets encouraging biking and walking: Coalition are the National Center for Safe Routes to 1. Incorporating sidewalks and bike lanes into community design. School and Smart Growth America. Safe Routes to School focuses specifically on encouraging and enabling 2. Providing funding for biking and walking in highway projects. more children to walk or bike to school, while Smart 3. Establishing safe routes to school. Growth America deals with issues related to community planning, including land use, mixed-use development, and 4. Fostering traffic-calming measures (e.g., any transporta- open-space preservation. tion design that is used to slow traffic). 5. Creating incentives for mixed-use development.255 54 BIKING AND WALKING TO SCHOOL Fewer students walk or bike to school in infrastructure improvements, such as build- the 21st century. According to a 2001 ing and improving sidewalks, and behavior National Household Travel Survey, less change campaigns to encourage children to than 16 percent of students between the bike or walk to school.260 ages of 5 and 15 walk or bike to school, The Illinois Department of compared with 48 percent in 1969.257 Transportation awarded $8.3 million to Also, a recent study by CDC found that support similar efforts. That money is part only 31 percent of students aged 5-15 who of the $23 million Illinois received in feder- live within one mile of school walk or bike; al grants to improve pedestrian and bicycle in 1969, that percentage was close to 90.258 safety projects across the state over the After introducing new safety policies and pro- next 3 years (2008-2010).261 motional activities in Marin County, California, The California Department of the percentage of students walking to school Transportation has awarded $196 million to increased by 64 percent in just two years.259 over 700 Safe Routes to School projects Several states have undertaken comprehen- since the program’s inception in 2000.262 The sive campaigns to encourage more students latest round of grants will distribute $52 mil- to bike and walk to schools. For example: lion to cities and counties for various street safety projects, such as improved lighting at The Ohio Department of Transportation crosswalks. In addition, the 2008 grant launched a $4-million Safe Routes to School money will be used to promote walking and campaign in 2008 to enhance pedestrian biking through educational programs.263 safety. Part of the campaign will focus on 55 D. QUALITATIVE EVALUATION OF STATE OBESITY-RELATED LEGISLATION As part of this year’s report, TFAH partnered tions/entities are given the discretion to with the STOP Obesity Alliance and the George depart from such standards. Washington University School of Public Health I Enforcement mechanism: Whether the law and Health Services’ Department of Health provides for some type of public enforce- Policy to conduct a qualitative review of state ment mechanism (sanction, incentive, pub- laws that are related to the prevention or treat- lication of results, private enforcement). ment of obesity. The review focused on laws in 2 major domains: nutrition and physical activity I Data collection. Whether the law requires standards in schools and insurance coverage states to collect data on the performance for obesity-related treatments. Within these 2 of affected public and private entities. major domains, the assessment measured laws (Covered entities may be local units of against 4 factors: government, employers, or other public or private entities.) I Objective standards: The extent to which state laws either adopt (or specify the adoption The research team defined “objective stan- of) objective standards related to obesity dards” as federal or national standards that prevention or treatment intervention.264 have achieved either: I Statewideness: Whether the standards that I National recognition as a widely used or are adopted or contemplated in a state recommended standard, or law are expected to be applicable on a I Status as a formal legal standard. statewide basis or whether local jurisdic- QUALITATIVE ANALYSIS RESEARCH TEAM Faculty and Staff from the George Washington University School of Staff from TFAH: Public Health and Health Services’ Department of Health Policy: Rebecca St. Laurent, JD Nancy Lopez, JD MPH Jennifer Sheer, MPH Jennifer Lee, MD Laura Cohen Sara Rosenbaum, JD 1) PHYSICAL ACTIVITY AND NUTRITION STANDARDS IN SCHOOLS All 50 states and D.C. mandate physical edu- Although all states have some form of legisla- cation in schools as part of the public school tion related to physical education and/or curriculum (although participation is not physical activity in schools, the majority do always mandatory). However, without not have specific enforceability language. enforcement mechanisms there is no way to Thirteen states were found to have enforce- make sure schools are following the rules. ability language. Of those states, 4 included Likewise, 18 states currently have require- sanctions or penalties within their language, ments for school meals that exceed the nutri- and 10 included collection and reporting of tion standards set by USDA. In this analysis information regarding performance lan- researchers examined all state legislation relat- guage, with one state containing both types ing to physical activity/education and nutri- of language. Of the 18 states that have school tion in the schools of each state, and evaluated meal requirements exceeding the USDA whether or not there is express enforceability standards, only 7 have specific enforceability language within that legislation. language, with only 2 including sanctions or penalties for noncompliance. 56 STATE PHYSICAL ACTIVITY AND NUTRITION LAWS State Physical Activity Laws Contain Nutrition Laws Contain Express Express Enforceability Provision Enforceability Provision 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 Please Note: Checkmarks in chart above followed by * indicate enforceability in the form of the collection of information regarding performance and checkmarks followed by a ^ indicate enforceability in the form of sanctions or penalties. 57 2) INSURANCE BENEFITS FOR OBESITY-RELATED TREATMENT Over the past 5 years, the insurance industry’s nutrition counseling, reimbursement for vis- view of obesity and obesity-related health its to the doctor, as well as access to 2 pre- problems has undergone a dramatic change. scription weight-loss drugs.269 BCBSNC also started including registered dieticians in its When insurers first recognized obesity as a network of providers. All those covered by substantial health risk, procedures such as BCBSNC can receive up to 6 nutrition visits bariatric surgery became available within per year.270 Highmark, which is a Pittsburgh- some private insurance plans.265 However, based insurance company, has also begun to even with evidence showing that nutritional reimburse pediatricians for obesity counsel- counseling can help obese patients lose ing.271 The statistics to date show that obesity weight and that prevention and treatment related visits have increased by 23 percent.272 of obesity work best when provided by a multidisciplinary team of health care work- Another change occurred in February 2006 ers, most insurance policies did not include when the Centers for Medicare and coding for obesity counseling.266,267 The fail- Medicaid Services (CMS) released its new ure to provide coding means that clinicians policy that includes national coverage for who want to offer obesity treatments and bariatric surgery.273 The new policy extends preventive services have no way of billing for bariatric surgery to all Medicare recipients these services. If health care workers are with a body mass index of 35 or higher with unable to be reimbursed for their services, at least one co-morbidity related to obesity.274 they are highly unlikely to offer these obesi- Given the recent developments in insurance ty-related services to their patients. coverage of obesity-related treatments, In recent years, however, that has begun to researchers examined each state’s coverage in 3 change. In late 2004 Blue Cross and Blue areas: Medicaid Early and Periodic Screening, Shield of North Carolina (BCBSNC) Diagnostic, and Treatment (EPSDT), Medicaid announced that it would begin offering cov- adult obesity coverage and payment for eligible erage for obesity.268 The coverage includes persons, and state insurance laws. a) Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medicaid requires participating states to cover In covering health treatments for children, Early and Periodic Screening, Diagnostic, and states are expected to adhere to standards of Treatment (EPSDT) benefits for all eligible medical necessity that reflect accepted pedi- children under age 21, even if such services are atric standards of care. not available under the state’s Medicaid plan to In 2005 the American Medical Association, in the rest of the Medicaid population. EPSDT collaboration with the Health Resources and benefits include comprehensive periodic and Services Administration and CDC, convened as-needed assessments of children’s health and an expert committee to provide updated development beginning at birth and continu- practical guidance to practitioners on how to ing to age 21. The examinations encompass a prevent, assess, and treat child and adolescent wide range of procedures, including a devel- overweight and obesity.275 The committee put opmental assessment, a nutritional assessment, forth guidance based on their appraisal of the and anticipatory guidance. For children iden- literature and their collective clinical experi- tified with a physical, developmental, or men- ence. These recommendations, published in tal health condition, states must arrange for all December 2007, represent the consensus of medically necessary treatments falling within experts based on the best available informa- federally covered service classes, even if such tion at the time and have been well-received treatments or service classes are not available by the provider community. for individuals ages 21 and older. 58 State Medicaid EPSDT Coverage and Treatment Standards for Child Obesity State EPSDT reimbursement reflects evidence-based EPSDT provider manual includes obesity treatment standards for nutritional detailed treatment standards for assessment and counseling child overweight and obesity Alabama a* _ Alaska + _ Arizona + _ Arkansas a* _ California _ _ Colorado _ _ Connecticut b * _ Delaware a 1 DC a† 1 Florida a 2 Georgia a 1 Hawaii _ _ Idaho b _ Illinois a 2 Indiana + _ Iowa + 1 Kansas + 1 Kentucky + _ Louisiana b * _ Maine b * _ Maryland a 2 Massachusetts a* 1 Michigan _ _ Minnesota b _ Mississippi b _ * Prior authorization required Missouri _ _ † Could not find fee schedule on Montana + _ state Medicaid website Nebraska b * _ Nevada b * _ P Services will be covered as part of New Hampshire b * _ prenatal care only New Jersey _ _ C Services will be considered only if New Mexico + _ comorbid conditions exist New York _ 1 L Services specifically limited (North North Carolina b * _ Dakota limits patient to four dietitian North Dakota b _ visits per year and specifically Ohio _ _ excludes any weight loss or exercise Oklahoma + _ programs) Oregon b _ 1 EPSDT manual provides details on Pennsylvania b _ obesity assessment but not treatment Rhode Island b _ South Carolina b _ 2 EPSDT manual provides details on South Dakota _ _ obesity assessment and treatment Tennessee a† _ a Manual specifies the state will pay Texas _ 1 for nutritional assessment and coun- Utah b * _ seling but CPT codes are not listed Vermont b 2 to bill for these services Virginia b _ b Manual does not specifically men- Washington + _ tion whether state will pay for nutri- West Virginia b _ tional assessment and counseling Wisconsin b * _ but CPT codes are listed to bill for Wyoming b 1 these services Symbol Rating Obesity Treatment Services + Strong evidence of reimbursement; Manual specifies the state will pay for nutritional assessment and counseling and CPT codes are listed to bill for these services Some evidence of reimbursement; Either manual specifies state will pay for nutritional assessment and counseling or CPT codes are listed to bill for these services _ Manual does not specifically mention whether states will or will not pay for nutritional assessment and counseling and no CPT codes are listed to bill for these services 59 Based on each state’s published Medicaid therapy in children with overweight and manuals and fee schedules, researchers obesity. These states not only provide guid- found 10 states that failed to address nutri- ance in their provider manuals and regula- tional assessment and counseling reimburse- tions for the coverage of these services but ment at all in their published materials. In also provide reimbursement amounts in these states, neither the provider manual their fee schedules for related billing codes. specifically mentioned whether Medicaid For those states that listed medical nutri- would pay for these services nor were CPT tion codes in their fee schedules, the reim- codes listed to bill for these services. In these bursement rate for a 15 minute individual states, it only can be assumed that these serv- assessment by a dietitian ranged from $9.91 ices are not likely to be reimbursed. to $32.21. The majority of states (29 and D.C.) provided Twelve states require prior authorization for some but not conclusive evidence that they services that are not normally covered by will reimburse for nutritional assessment and Medicaid. counseling. In general, these states either provided generalized and nonspecific guid- Four states set forth detailed treatment stan- ance regarding treatment for childhood con- dards for childhood obesity in their EPSDT ditions without listing reimbursement levels provider manuals. Nine states incorporated for related billing codes or they provided details on how to assess or screen for child billing codes without any specific language obesity in their EPSDT manuals, but did not directing providers to use these codes for include guidelines on how to treat obesity. nutritional assessment and treatment in the Some manuals included links to screening treatment of obesity. tools and guidelines and some states had child obesity treatment information avail- Researchers found that currently only 11 able elsewhere on their website (i.e. public states provide strong evidence that they will health departments) but not in their reimburse for nutritional and behavioral provider manuals. b) Medicaid Adult Obesity Coverage In 2004, the U.S. Department of Health and serious and chronic health conditions. As a Human Services (HHS) removed language result, the prevalence of elevated health from the Medicare Coverage Issues Manual risks and serious illness is significantly high- that stated obesity was not an illness.276 This er among the Medicaid population. policy change opened the door for the treat- State Medicaid programs have broad discre- ment under federal health care programs of tion over coverage and payment for services. obesity as an illness or condition in its own Medicaid specifies certain broad service right. The change also sets an important classes as required services; these include precedent for private insurers and employ- physician services, inpatient services, and er-sponsored health benefit plans, because services of federally qualified health centers of Medicare’s influence over health care and rural health clinics, and several other financing policy generally. service classes. However, not all procedures Medicaid is the largest of all public health within required services classes must be cov- benefit programs, covering over 58 million ered. Moreover, many service classes such people in 2005.277 Medicaid beneficiaries as prescribed drugs, preventive services fur- are low income or medically impoverished, nished by health professionals, and other and many Medicaid eligibility categories relevant service classes are not required but are, in contrast to private health insurance, remain optional with states. Most states designed to assure coverage for persons with cover most classes of optional services to at 60 least some degree. All states cover prescrip- merely mentioned, or were specific treat- tion drugs to an extensive degree. ment guidelines mentioned). The review of state Medicaid coverage and I The type of treatments covered and/or paid payment practices focused on 2 items: for (nutritional assessment/counseling, pharmacological therapy, and surgery). I The depth of guidance provided by the provider manual (i.e. was treatment 61 State Medicaid Coverage and Treatment Standards: Adult Obesity (Age 21 And Older) State State provides State covers and pays for State covers and pays State covers and pays specific guidance for nutritional assessment and for drug therapy for for bariatric surgery treatment of consultation for treatment the treatment of obesity for treatment of obesity in adults of obesity in adults in adults obesity in adults Alabama - - - +1 Alaska - +a,P - +* Arizona - +d 0 + Arkansas - 0 0 +* California - - 0 +* Colorado - - +* +2 Connecticut - - 0 + Delaware - +b,* +* +* D.C. - 0† 0 +* Florida - - 0 +3 Georgia + + - +* Hawaii - - 0 +* Idaho - +C 0 +4 Illinois - - 0 +5 Indiana - +d + + Iowa - +d +* +* Kansas - - - 0† Kentucky X +a 0 - Louisiana - +d + + Maine - +d 0 +* Maryland X 0 0 +* Massachusetts X 0 0 +6 Michigan - +d,P 0 +7 Minnesota - +a +* +* Mississippi - +d +* - Missouri X +d,C 0 +8 Montana X - 0 -9 Nebraska - - 0 +10 Nevada - +d 0 +11 New Hampshire - - 0 +12 New Jersey - - 0 0† New Mexico X - 0 +* New York X 0 0 +13 North Carolina - +d 0 +*, 14 North Dakota - +a,L 0 +* Ohio - - - +* Oklahoma - +d - +15 Oregon - +a,P 0 +* Pennsylvania - +d 0 +* Rhode Island - +d 0 +* South Carolina - +a,C +* +16 South Dakota - - 0 +17 Tennessee X - 0 +18 Texas - - 0 - Utah X - 0 +* Vermont +19 +d 0 +* Virginia - +a,P +* +* Washington - +a,P - + West Virginia - - 0 +*,20 Wisconsin - +a,L +* +* Wyoming - - - +21 62 * Prior authorization required a Manual specifies the state will pay for nutritional † Could not find fee schedule on state Medicaid website assessment and counseling and CPT codes are list- ed to bill for these services P Services will be covered as part of prenatal care only b Manual specifies the state will pay for nutritional C Services will be considered only if comorbid condi- assessment and counseling but CPT codes are not tions exist listed to bill for these services L Services specifically limited (North Dakota limits d Manual does not specifically mention whether state patient to four dietitian visits per year and specifically will pay for nutritional assessment and counseling excludes any weight loss or exercise programs) but CPT codes are listed to bill for these services Symbol Rating Obesity Guidance + Manual provides detailed guidance for treating adult obesity X Manual does not mention treating adult obesity - Manual provides no guidance for treating adult obesity Services + State covers and reimburses specified service 0 State does not mention specified services in manual - State specifically excludes coverage and reimbursement for specified service 1 Alabama will not cover Gastric Bypass for patients 12 New Hampshire does not cover CPT codes with a history of a previous Gastric Bypass proce- 43645 or 43845. dure. 13 New York does not cover CPT code 43845. 2 Colorado does not reimburse for CPT code 43845. 14 North Carolina does not cover investigational 3 Florida and West Virginia will not reimburse for procedures including jejunoileal bypass, biliopan- Bariatric Surgery unless there is an accompanying creatic bypass, gastric wrapping, gastric banding, co-morbidity. jejunocolostomy, and mini-gastric bypass. 4 Idaho will only cover Gastric Bypass if the patient 15 Oklahoma does not include CPT codes 43842 or also has: alveolar hypoventilation, uncontrolled 43843 in its fee schedule. hypoventilation, uncontrolled diabetes, uncontrolled 16 South Carolina will only cover surgery if a co- hypertension; also requires prior-authorization. morbidity is present. 5 Illinois and Wyoming approve gastric bypass on a 17 South Dakota does not cover CPT codes 43644, case-by-case basis. 43645, 43770, 43771, 43772, 43773, 43774, 6 Massachusetts will not cover CPT codes 43842, 43845, or 43848. 43843, or 43845. 18 Coverage offered is available through TennCare, 7 Michigan does not cover services for obesity alone; Tennessee’s managed care program. It is unclear it will cover treatment of obesity when done for if this service is covered through traditional fee the purpose of controlling life-endangering co- for service Medicaid. morbidities. 19 Vermont does not include obesity treatment lan- 8 Missouri will not cover SPT codes 43770, 43771, guage in its provider manual. However, the state 43772, 43773, or 43774. offers an extensive adult obesity toolkit at: 9 Montana has no CPT codes for obesity surgery in http://healthvermont.gov/family/fit/documents/Pro its fee schedule nor does it mention obesity in its moting_Healthier_Weight_toolkit.pdf. provider manual. 20 Florida and West Virginia will not reimburse for 10 Nebraska excludes Ileal bypass and intestinal Bariatric Surgery unless there is an accompany- surgery and will not cover other surgeries when ing co-morbidity. the sole diagnosis is obesity. 21 Illinois and Wyoming approve gastric bypass on a 11 Nevada excludes intestinal bypass and gastric case-by-case basis. balloon. 63 Medicaid Manual References to Obesity Treatment in Adults Specific guidelines were rarely referred to in Excluding the few states that made no men- the Medicaid provider manuals. Only 2 state tion of obesity (9 states), most provider man- manuals provided guideline references. uals (40 states) referred to it only in regard to Georgia referenced the Food Pyramid. While coverage issues, rather than diagnostic or Vermont made no mention of obesity within treatment guidance. Nebraska and South its provider manual, it did offer an extensive Carolina explicitly state in their provider man- toolkit for adult obesity on its website. uals that obesity is not an illness. State Medicaid Coverage and Payment All 50 states and D.C. explicitly cover at least Bariatric Surgery one treatment category. Eight states Bariatric surgery was the most frequently cov- (Delaware, Indiana, Iowa, Louisiana, ered treatment (45 states); it is also the least Minnesota, South Carolina, Virginia, and likely to be explicitly not covered (2 states). Wisconsin) cover all 3 treatment categories. Many state Medicaid programs do not offer Nutritional Assessment and Consultation adults a full range of treatment options. The Twenty-six states explicitly cover nutritional provider manuals suggest (and even outright assessment and consultation while 20 explicit- state) that obesity is not an illness or disease in ly do not. and of itself, suggesting that few states are yet following Medicare’s lead. Treatment is often Drug Therapy subject to many limitations and may not even Drug therapy is the least frequently covered be offered if a patient is not suffering from and discussed treatment category; only 10 additional illnesses that are negatively impact- states cover it while 33 make no mention of ed by obesity. What is most significant about it within their provider manuals. these results is the large amount of silence exhibited by the states in regard to the 3 types of obesity treatment considered here. 64 c) State Insurance Laws Privately insured persons are overwhelming- ical condition by HHS, it can be argued that ly insured in the group market, with only 5 obesity falls within “health status” defini- percent of insured persons covered through tions, which vary from state to state. non-group individual or family insurance, This analysis examines 3 basic aspects of where medical underwriting is prevalent. state insurance law: Persons with obesity may be excluded from the individual market based on their obesity I The extent to which states prohibit or regu- alone. Furthermore, insurers may use body late medical underwriting practices involving mass index measurements (BMI) to classify obesity or “health status” as an independent certain persons as “unhealthy” or “uninsur- risk factor in the small group market. able” as a result of their weight. In the I The extent to which states prohibit or reg- absence of explicit state regulation, an insur- ulate medical underwriting practices er would be not only be free to use obesity or involving obesity or “health status” as an weight to impose exclusions and adjust rates, independent risk factor with regard to but also to define the terms “overweight” both eligibility and rate adjustments in and “obese” at their discretion. the individual market. Additionally, unless a state expressly pro- I The extent to which state insurance hibits its use, “health status” can be an inde- laws address coverage of obesity related pendent risk factor in medical underwrit- treatments. ing. Because obesity is now deemed a med- 65 State Health Insurance Law & Regulations State State prohibits or regulates medical underwriting State requires coverage of one or or exclusions involving obesity or health status more obesity related treatments. as an independent risk factor. Small Groups Individual Small Groups Individual For Eligibility For Rate Setting Alabama 0 0 0 0 0 Alaska -1 0 0 0 0 Arizona -2 0 0 0 0 Arkansas -3 0 0 0 0 California -4 -5 -6 0 0 Colorado -7 0 0 0 0 Connecticut +8 0 0 0 0 Delaware -9 0 0 0 0 DC 0 0 0 0 0 Florida -10 0 0 0 0 Georgia 0 0 0 (+)11 (+)12 Hawaii 0 0 0 0 0 Idaho -13 0 -14 0 0 Illinois - 15 0 0 0 - 16 Indiana 0 0 0 + 17 0 Iowa - 18 0 0 0 0 Kansas 0 0 0 0 0 Kentucky - 19 0 - 20 0 0 Louisiana* - 21 0 - 22 0 0 Maine + 23 + 24 + 25 0 0 Maryland + 26 0 0 + 27 + 28 Massachusetts + 29 + 30 +31 0 0 Michigan - 32 0 033 0 0 Minnesota -34 0 - 35 0 0 Mississippi -36 0 0 0 0 Missouri - 37 0 0 0 0 Montana - 38 0 0 0 0 Nebraska - 39 0 0 0 0 Nevada - 40 0 - 41 0 0 New Hampshire - 42 0 0 + 43 + 44 New Jersey + 45 + 46 + 47 + 48 + 49 New Mexico - 50 0 0 0 0 New York + 51 + 52 + 53 0 0 North Carolina - 54 055 0 0 0 North Dakota - 56 0 0 0 0 Ohio - 57 0 0 0 0 Oklahoma - 58 0 0 0 0 Oregon + 59 - 60 + 61 0 0 Pennsylvania 0 0 0 0 0 Rhode Island - 62 0 0 0 0 South Carolina - 63 0 - 64 0 0 South Dakota - 65 0 - 66 0 - 67 Tennessee - 68 0 069 0 0 Texas - 70 071 - 72 0 0 Utah - 73 0 - 74 (-)75 (-)76 Vermont + 77 + 78 + 79 0 0 Virginia - 80 0 0 + 81 + 82 Washington + 83 0 + 84 0 0 West Virginia - 85 0 0 0 0 Wisconsin - 86 0 0 0 0 Wyoming - 87 0 0 0 0 66 Symbol Rating Category 1: State prohibits or regulates medical underwriting or exclusions involving ‘obesity’ or ‘health status’ as an independent risk factor. (-) The state has a statute that expressly allows for rate adjustments based on either health status or obesity in the small group market OR expressly allows health status or obesity to be used in determining eligibility or adjusting rates in the individual market. (+) The state has a statute that expressly prohibits adjustments in rates based on health status or obesity in the small group market OR prohibits the use of obesity or health status to determine eligibility or rates in the individual market. (0) The state is silent with regard to obesity or health status being used to determine rates in the small market OR eligibility or rates in the individual market. Category 2: State requires coverage of one or more obesity related treatments. (-) The state has a statute that expressly prohibits the coverage of obesity related treatment(s). (+) The state has a statute that expressly allows the coverage of obesity related treatment(s). (0) The state is silent on the issue of coverage for obesity related treatment(s). 1 AS 21.56.120 16 Illinois Insurance Code Title 50 Chapter 1 2 Arizona Code 20-2311 §2007.60(e)(17) (No individual policy shall limit or exclude coverage by type of illness, accident, treatment 3 Arkansas Insurance Code §23-86-204 or medical condition, except as follows... “weight 4 California Code §10716 reduction procedures, treatment or classes, except for 5 BMI CA Insurance Code §10113.95 created a require- morbid obesity”) ment for insurers of individual health insurance policies 17 Indiana Insurance Code 27-8-14.1-4 (a group insurer to file rating policies and underwriting guidelines with “that issues an accident and sickness insurance policy Dept. of Insurance (AB 356). The Dept. of Insurance shall offer coverage for nonexperimental, surgical summarized the information that companies filed in the treamtment by health care provider of morbid questions and answers chart below: Will a health insur- obesity”....some caveats listed in statute) §27-13-7- ance company look at my height and weight when I 14.5 (same coverage for group HMO’s) apply for insurance? Yes. Insurance companies usually 18 Iowa Insurance Code §513B.4 look at your height and weight when they decide to offer insurance. They may offer you insurance at a higher pre- 19 Kentucky Insurance Code §304.17A-0952 mium rate or refuse to insure you if you are overweight 20 Ibid. or obese. Some insurance companies use a measure- 21 Louisiana Insurance Code §22:228.2 ment called the Body Mass Index (BMI) to decide. If 22 Louisiana Insurance Code §22:228:6 your BMI is above 39, most insurance companies will not *Louisiana Public Health Code RS40:1299.117 interest- offer you insurance. If your BMI is 30-39, an insurance ingly states that obesity is a disease if accompanied by company may offer you insurance at a higher premium. one of eleven conditions/comorbidities. If you have health problems because of your weight, such as diabetes or heart disease, an insurance company 23 Maine Insurance Code Title 24-A Chapter 35 §2808- may refuse to insure you, even if your BMI is under 30. B (‘a carrier may not vary the premium rate due to gender, health status, claims experience, or policy 6 BMI duration of eligible group) 7 Colorado Revised Statute §10-16-105 24 Maine Insurance Code §2736-C -medical underwriting 8 Adjusted Community Rating: Connecticut Insurance is prohibited; Adjusted Community Rating for Code 38A-567 (No small employer carrier may inquire premiums -- cannot use health status to adjust regarding health status or claims experience of the 25 Ibid. small employer or its employees or dependents prior to the quoting of a premium rate) 26 Maryland Insurance Code §15-1205 (community rat- ing for small group insurance - “rating methodology 9 Delaware Code Title 18 §7202 ...without regard to health status”) 10 Florida Code §627.6699(6) 27 Ibid. 11 GA Insurance Code 33-24-59.7 (Every health benefit 28 Maryland Insurance Code §15-839 (“An entity subject policy that is delivered, issued, executed, or renewed to this section shall provide coverage for the surgical in this state... on or after July 1, 1999, which provides treatment of morbid obesity”...caveats listed) major medical benefits may offer coverage for the treatment of morbid obesity.) 29 Massachusetts Chapter 58 of the Code of 2006 (176J(4)(a)(3) & 176Q) (reform law prohibits exclud- 12 Ibid. ing anyone on health status) (group insurance is com- 13 Idaho Code Title 41 Chapter 47 §41-4706 munity based rating with adjustments allowed for age, 14 Idaho Code §41-5206 (see §41-5208 for limits on industry, group size, geography, family composition, catastrophic insurance) participation rate, wellness program participation, and 15 §215ILCS93/25 participation in the small employer reinsurance plan.) 67 30 176M- guaranteed issue and adjusted community 59 OAR 836-053-0065 (Bulletin prohibiting the use of rating for premiums health status to be used in underwriting in small 31 Ibid. group insurance policies) modified community rating 32 Michigan PA 88 of 2003: underwriting is permitted by 60 Oregon Insurance Code §743.766 health status with the exception of BCBS and HMOs 61 Oregon Insurance Code §743.767(2) adjusted which exclude health status underwriting. BCBS can community rating only consider age and industry and HMOs can only 62 OFFICE OF THE HEALTH INSURANCE consider age, industry, and group size. COMMISSIONER REGULATION 11 SMALL 33 Ibid. EMPLOYER HEALTH INSURANCE AVAILABILITY 34 Minnesota Code 62L.08 REGULATION Section 5 35 Minnesota Code 62A.65 63 South Carolina Insurance Code SECTION 38-71-940 36 Mississippi Code §83-63-7 64 South Carolina Insurance Code Section 38-71-325 37 Insurance Code §379.936 65 South Dakota Insurance Code §58-18B-3; 38 Montana Insurance Code §33-22-1809 66 South Dakota Insurance Code §58-17-74 (expressly allows weight to be used as rating factor); SD 39 Nebraska Code §44-5258 Administrative Rules 20:06:39:03 40 Nevada Code NRS 689C.210 67 South Dakota Administrative Regulations 20:06:39:29 41 Nevada Code NRS 689A.680 (expressly allows exclusion for weight modifica- 42 New Hampshire Insurance Code §404-G:5-d tion....obesity treatments..surgery..) 43 New Hampshire Insurance Code RSA 415:18-t 68 Tennessee Insurance Code §56-7-2209 (coverage for the diseases and ailments caused by 69 Cover Tennessee Program allows obesity to be used obesity and morbid obesity and treatment for such, as risk factor is assessing premiums §56-7-3013 (small including bariatric surgery”...with caveats) (SB312) group employers can buy into the program) 44 New Hampshire Insurance Code RSA 415:6-o 70 Texas Insurance Code §1501.205 (coverage for the diseases and ailments caused by 71 Under Texas Administrative Code 28 Part 1 Chapter obesity and morbid obesity and treatment for such, 11 subchapter H Rule 11.04(a) individual HMO’s do including bariatric surgery”...with caveats) not use health status as factor in underwriting policies. 45 New Jersey Insurance Code NJSA 17B:27A-25 (modified 72 Texas Insurance Code §544.155 community rating required for small group insurers) 73 Utah Insurance Code §31A-30-106 46 New Jersey Insurance Code NJSA 17B:27A-4 (community rating required for individual insurers; 74 Utah R590-167-6 guarantee issue) 75 Utah Administrative Rules R590-233-4(w) (allows 47 Ibid. gastric bypass surgery to be excluded from group and individual heath insurance policies) 48 New Jersey Insurance Code 17B:27-46.1h (provides for “annual consultation with a health care provider 76 Ibid. to discuss lifestyle behaviors that promote health and 77 Vermont Insurance Code Title 8, Chapter 107, well-being including, but not limited to... nutrition and 4080a(h)(1) prohibits the use of medical underwriting diet recommendations, exercise plans, lower back in group policies. protection, weight control” 78 Vermont Insurance Code Title 8, Chapter 107, 49 New Jersey Insurance Code 17B:27-2.1.h (provides 4080b(h)(1) prohibits the use of medical underwriting for “annual consultation with a health care provider in individual policies; 4080d(1) guaranteed issue to discuss lifestyle behaviors that promote health and 79 Ibid. well-being including, but not limited to... nutrition and 80 Virginia Insurance Code §38-2-3433 diet recommendations, exercise plans, lower back protection, weight control”) 81 Virginia 38-2-3418.13 allows for coverage of treatment for morbid obesity for group and individual policies. 50 New Mexico Insurance Code §59A-23C-5 82 Ibid. 51 New York Insurance Code 11 NYCRR 360.4; 360.5 (prohibits medical underwriting; pure community rating) 83 Washington Insurance Code §48.44.035 (adjusted community rating) 52 Ibid. 84 RCW 48.44.022 -- health status prohibited from 53 Ibid. being used for adjustment of premium rates but does 54 NC Insurance Code §58-50-130 not determine eligibility for coverage or exlusions. 55 BCBS has some guaranteed issue policies but can 85 WV §33.16D5 charge high premiums 86 Wisconsin §632.748; §932.05 56 North Dakota Insurance Code §26.1-36.3-04 87 Wyoming Insurance Code §26-19-304 57 Ohio Insurance Code §3923.571 58 Oklahoma Title 36 Chapter 2 §6515 68 Medical Underwriting or Exclusions factor to determine rates in the individual Essentially insurers have the liberty to use market. South Dakota is the only state to obesity or health status as a risk factor to expressly state that “weight” can be used as a deny coverage and exclude treatments, rating factor; the other 9 states allow “health unless otherwise prohibited by state law. status” to be used as a rating factor. On the group market, 35 states expressly Mandated Coverage for One or More allow health status or obesity to be used as a Obesity-Related Treatment factor for rate adjustments in the small The vast majority of states do not mandate group market. The majority used “health any coverage of obesity related treatments status” as an adjustment factor. Only 9 states and the few that do cover only those treat- prohibit the use of health status or obesity as ments for morbid obesity as long as individ- a factor for rate adjustments in the small uals adhere to the caveats imposed in the group market. These states used communi- coverage requirement. Only 5 states pro- ty or adjusted community rating. vide for coverage of one or more treatments Five states prohibit the use of health status or for obesity for both the small group and obesity as a factor to determine eligibility in individual insurance markets: Georgia, the individual market. These states are Maine, Maryland, New Hampshire, New Jersey, and Massachusetts, New Jersey, New York and Virginia. Indiana provides for coverage of Vermont. Meanwhile, 7 states prohibit the use surgical treatment of morbid obesity for of health status or obesity as a factor to deter- groups only, while Illinois and South Dakota mine rates in the individual market -- Maine, expressly exclude coverage for obesity relat- Massachusetts, New Jersey, New York, Oregon, ed treatments in the individual market only. Vermont, and Washington. Utah is the only state that expressly excludes gastric bypass surgery from coverage in both For the individual market, 2 states expressly markets. allow the use of health status or obesity as a factor to determine eligibility in the individ- Although obesity itself is being treated more ual market -- Oregon (through mandatory like a disease with drugs, surgery, and use of standardized health form) and behavior therapy in various combinations, California (through mandatory filing of the health insurance system has still largely insurers’ rates based on BMI). Ten states ignored the problem. allow the use of health status or obesity as a 69 Federal Responsibilities and Policies 4 SECTION T here are a variety of initiatives to promote physical activity and healthy nutrition at the federal level. This section includes a discussion of fed- eral obesity-related policies and legislation, including major bills that were up for reauthorization in 2008 or that are due to be considered in 2009. A. Overhaul of the WIC Food Packages. F. Reauthorization of the Safe, Accountable, Flexible, Efficient Transportation Equity B. 2008 Farm Bill. Act: A Legacy for Users (SAFETEA-LU). C. Reauthorization of the Child Nutrition Act. G. Other Obesity Related Legislation before D. Reauthorization of the No Child Left Congress. Behind Act. H. Funding for CDC Obesity Grants. E. Reauthorization of the State Children’s Health Insurance Program (SCHIP). A. OVERHAUL OF THE WIC FOOD PACKAGES In December 2007, USDA made significant The new WIC list of approved foods con- changes to the Special Supplemental Nutrition tains all the old items plus:280 Program for Women, Infants, and Children I Fruits (fresh, frozen, dried or canned) (WIC) adding fruits, vegetables, and whole I Vegetables (fresh, frozen, dried or canned) grains to the list of grocery items covered. This I Whole wheat bread or other whole grains was the program’s first major overhaul since I Soy-beverage & tofu 1974.278 A 2005 report by the IOM had called I Light tuna for similar action on the grounds that “the pro- I Salmon posed changes to the WIC food packages hold I Sardines potential for improving the nutrition and I Mackerel health of the nation’s low-income pregnant I Canned legumes women, new mothers, infants, and young chil- I Infant foods dren.”279 USDA based its recommendations on The new food list incorporates a diverse those in the 2005 IOM report. group of foods in order to appeal to partici- Under the old regulations, WIC participants pants from various cultural backgrounds.281 were able to purchase the following items: According to the National WIC Association, I Iron-fortified infant formulas these changes will not only impact the I Milk health of mothers and children enrolled in I Cereal (infant and adult) the program, but others in the community I Juice who shop at WIC-authorized grocery stores I Eggs as these retail outlets will now be required to I Cheese carry this variety of fresh, healthy food.282 I Dried legumes or peanut butter I Tuna The changes to WIC also include incentives I Carrots to promote breastfeeding among low- 71 income women, who have lower rates of etable vouchers women who breastfeed breastfeeding according to CDC.283 receive, while providing less formula to par- Research indicates that formula-fed chil- tially breastfed infants. dren have higher risks of ear and respirato- States have until Oct. 1, 2009, to implement ry infections, obesity, diabetes, and cancer.284 the new WIC regulations, but many have The WIC program aims to more vigorously moved to implement them ahead of the promote and support breastfeeding by deadline. increasing the amount of fruit and veg- B. 2008 FARM BILL In June, the House and Senate both passed the I Indexes the asset limit to keep pace with Food, Conservation, and Energy Act of 2008 inflation and excludes the value of retire- (P.L. 110-246). The legislation reauthorizes ment and education savings accounts farm and nutrition programs for the next 5 from counting towards the asset limit. years. It includes an additional $10.36 billion I Requires the Secretary of Agriculture to over current spending levels for nutrition pro- carry out pilot projects to develop and test grams. The president vetoed the bill, but the methods of using the SNAP to improve the House and Senate overrode the veto. Below is dietary and health status of households eli- a summary of some of the key nutrition provi- gible for or participating in the SNAP and sions in the bill: to reduce overweight, obesity and associat- Food Stamps ed co-morbidities in the United States; I Renames the Food Stamp Program the requires that the secretary not use more “Supplemental Nutrition Assistance than $20 million in mandatory funding to Program” (SNAP). carry out a point-of-purchase pilot pro- gram to encourage households participat- I Raises and indexes the standard deduc- ing in the SNAP to purchase fruits, vegeta- tion and increases the minimum monthly bles or other healthy foods. benefit for food stamp recipients. 72 THE FOOD STAMP PROGRAM AND OBESITY In FY 2007, the Food Stamp Program (FSP) -- show that there may be a connection now known as the Supplemental Nutrition between the FSP and obesity. For example, a Assistance Program (SNAP) -- served approx- recent study funded by USDA found that low- imately 26.5 million people in an average income women who participate in the FSP month and cost about $33 billion.285 While are significantly more likely to be obese than this is clearly an important public assistance low-income women who are not participants program for many Americans, research data of the program.286 Obesity Differences Among Low-Income Food Stamp Recipients and Low-Income Non-Recipients WOMEN (Low-Income) Food Stamp Recipients Non-Recipients Prevalence of Obesity (%) 27.8 19.0 MEN (Low-Income) Food Stamp Recipients Non-Recipients Prevalence of Obesity (%) 21.3 20.1 Source: USDA, September 2007. USDA has been trying to address this prob- play a minor role in increasing the prevalence lem. The agency is examining assistance pro- of obesity nationwide.288 grams, poverty, and other factors that may A number of health advocacy organizations be contributing to disparities of higher levels raise the issue that many food stamp beneficiar- of obesity in lower-income populations. ies have difficulty affording many healthier food Many studies have been funded by USDA to options, since many healthier foods cost more provide an overview of the relationship than less healthy alternatives.289 Nutrition advo- between FSP and obesity. “Obesity, Poverty, cates suggest that economic incentives be pro- and Participation in Food Assistant vided to increase fruit, vegetable and other Programs,” publicly released in February of healthy food consumption through the FSP290 . 2005, basically concludes that despite efforts Also, the 2007 study suggests that the FSP at quality research, the effects of food assis- should be used as a tool to combat obesity by tance programs are still unknown.287 A more educating newly certified Food Stamp recipi- recent USDA study, “The Effects of Food ents about healthy eating habits and weight Stamps on Obesity,” released in September management.291 The reauthorized Farm Bill of 2007, reports that even if food stamps contains a provision to develop and test pilot caused all recipients to become obese (which programs to focus on these 2 issues. the data do not support), FSP would only 73 Seniors Communities I Reauthorizes the Commodity Supplemental I Provides $5 million of mandatory funding Food Program, which provides nutritious each year for Community Food Projects, food boxes primarily to low-income seniors. which are community-based projects that require a one-time contribution of feder- I Provides $20.6 million in mandatory fund- al assistance to become self-sustaining ing each year for the Senior Farmers’ and are designed to meet the food needs Market Nutrition Program, which provides of low-income individuals and to increase seniors with vouchers to buy fresh produce the self-reliance of communities in pro- at farmers’ markets, roadside stands, and viding for food needs. other community-supported programs. I Creates the Healthy Urban Food Children Enterprise Development Center to I Provides for a nationwide expansion of increase access to healthy, affordable the Fresh Fruit and Vegetable Program, foods, including locally produced agricul- which provides free fresh fruits and veg- tural products, to underserved communi- etables to be served as snacks to school- ties, and provides mandatory funding of children; requires state agencies to reach $1 million per year for the Center. out to schools with significant numbers of children eligible for free or reduced-price I Increases funding by $1.256 billion for meals to inform them of their eligibility the Emergency Food Assistance Program, for the program; and authorizes mandato- which provides commodities to help stock ry funding of $40 million for the program food banks. in 2008, $65 million in 2009, $101 million I Devotes additional mandatory funding to in 2010, $150 million in 2011, and $150 the Farmers’ Market Promotion Program million indexed for inflation in 2012. (FMPP), which provides grants to help I Requires the Secretary of Agriculture to promote farmers’ markets, roadside carry out a nationally representative sur- stands and other direct producer-to-con- vey of the foods purchased by school sumer marketing opportunities, and stip- authorities participating in the school ulates that some of the funding for the lunch program and provides $3 million to FMPP must be used to support the use of carry out the survey. electronic benefits transfers for federal nutrition programs at farmers’ markets. I Directs the Secretary to purchase fresh fruits and vegetables to be served for lunch in schools and service institutions and pro- vides $50 million a year for the acquisitions. C. REAUTHORIZATION OF THE CHILD NUTRITION AND SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) ACT The School Lunch and Breakfast Programs I National School Lunch Program. and Special Supplemental Nutrition I National School Breakfast Program. Program for WIC will be up for reauthoriza- tion in 2009. The legislation covers virtual- I Summer Food Service Program. ly all federal child nutrition and special sup- I Child and Adult Care Food Program. plemental nutrition programs, including the following: I WIC Program. 74 These programs are administered by Child Nutrition and Special Supplemental USDA’s Food and Nutrition Service in coor- Nutrition Program for Women, Infants, and dination with state education, health, social Children (WIC) Act (P.L. 108-265).301 They service, and agriculture agencies. There are include: 3 main goals of these federal child nutrition I Requiring local education agencies (i.e. programs: 1) improve children’s nutrition, school districts) which participate in 2) increase lower-income children’s access school meal programs to establish school to nutritious meals and snacks, and 3) help wellness policies that include goals for support the agricultural economy.292 nutrition education and physical activity, An estimated 39 million children and 2 mil- nutrition guidelines for foods available lion lower-income pregnant/postpartum during the school day, and a plan to meas- women are served by these programs.293 ure implementation. A number of dietary factors are contributing I Authorizing grants to states to implement to increased levels of childhood and adult obe- TeamNutrition Networks that support sity in America, ranging from higher caloric nutrition education through the promo- density of foods to limited access to nutritious tion of active lifestyles, pilot projects, data fresh foods in many areas to outdated nutri- gathering, and other activities. The Act tion standards for foods sold at schools. authorized grants to entities with expert- Currently, the typical American diet does not ise in health education programs for indi- include enough fruits and vegetables. viduals with limited English proficiency to enhance obesity prevention; authorized I Only one in 5 Americans consumes the technical assistance and grants to improve recommended amount of fruit each day.294 the quality of school meals; and author- I Children under the age of 18 generally ized grants to local educational agencies consume 50 percent or less of the recom- to create healthy school environments. mended levels of fruits and vegetables.295 I Making permanent the fresh fruit and Consumer and industry economics also con- vegetable snack program in schools. tribute to the country’s obesity problem. I Increasing the limit on the federal share I Low-income families consume fewer of benefits from $20 to $30 per partici- fruits and vegetables than higher-income pant per year for the WIC Farmers’ families.296 Market Nutrition Program, which pro- vides vouchers to WIC recipients to pur- I People in low-income areas often pay chase fruit and vegetables at farmers’ more for nutritious foods such as fresh markets. It also enabled states to expand fruits and vegetables.297,298 the definition of “farmers’ markets” to I The costs of fruits and vegetables have include road side stands. increased 40 percent since 1985, while the I Authorizing funding for USDA to encour- costs of fats and sugars have declined.299,300 age schools to purchase locally produced There are a number of nutrition provisions foods. It also authorized USDA to pro- associated with the reauthorization of feder- vide competitive matching grants and al programs. Advocates argue that these can technical assistance for projects that be an important vehicle to improve federal improve access to local foods through child nutrition programs and help combat farm-to-cafeteria activities, procurement the obesity epidemic. from small and medium-sized farms, sup- port for garden programs, and farm- A 2006 report by the Congressional Research based nutrition education projects. Service highlighted some key nutrition provi- sions authorized under the 2004 version of the 75 D. REAUTHORIZATION OF NO CHILD LEFT BEHIND The Elementary and Secondary Education the Fitness Integrated with Teaching (FIT) Act, widely known as the No Child Left Kids Act of 2007 (S. 2173/H.R. 3257). The Behind Act (NCLB), was due for reautho- legislation was introduced by Senator Tom rization in 2007, but Congress still has not Harkin (D-IA) and Representatives Ron Kind reauthorized it. Parts of the legislation could (D-WI), Zach Wamp (R-TN) and Jay Inslee influence how physical education and physi- (D-WA), and includes reforms that could be cal activity are included within the school day. included in the reauthorization of NCLB. Specifically, the FIT Kids Act would: require According to the National Coalition for state and local educational agency report Promoting Physical Activity (NCPPA), stud- cards to include information on school ies demonstrate that physical education and health and physical education programs; physical activity programs have positive include the promotion of active lifestyles in effects on students’ academic achievement, educational grant programs; support profes- including increased concentration, sional development for teachers and princi- improved mathematics, reading, and writ- pals to promote healthy habits and participa- ing test scores, and also reduced disruptive tion in physical activity; and fund a study by behavior.302 (See Section 3: State Responsibilities the National Academy of Sciences to assess and Policies for a further discussion of physical the impact of health and physical activity on activity and academic performance.) student achievement and find ways to make One of the major pieces of legislation and measure improvements to health and addressing physical activity in schools, that physical education in schools. may be offered as an amendment to NCLB, is E. REAUTHORIZATION OF THE STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP) ACT The State Children’s Health Insurance thus, these benefits may not be part of the Program (SCHIP) is designed to help states “benchmark” plans from which SCHIP cov- insure more low-income children who are not erage is developed. In order to more eligible for Medicaid. The program was up effectively address rising childhood obesity for reauthorization in 2007, but Congress and rates, basic anti-obesity benefits could be the president could not reach agreement on provided for SCHIP beneficiaries. There is a long-term reauthorization. As a result, the precedent for this sort of coverage as president signed a short-term extension of Medicare covers medical nutrition therapy the program, until March of 2009. When the for beneficiaries with diabetes or renal dis- program is revisited, Congress may again con- ease. But the Medicare benefit, which is sider taking steps to further address the child- aimed at adults familiar with medical hood obesity crisis by including a health advice, counseling, and treatment, may not insurance-style benefit for obesity-related be adequate for children covered by services to children enrolled in the program. SCHIP. (See Section 3: State Responsibilities and Policies for a more detailed analysis of obe- Most private insurance plans do not pro- sity-related insurance coverage.) vide coverage for obesity-related services; 76 F. REAUTHORIZATION OF THE SAFE, ACCOUNTABLE, FLEXIBLE, EFFICIENT TRANSPORTATION EQUITY ACT: A LEGACY FOR USERS (SAFETEA-LU) The Safe, Accountable, Flexible, Efficient time physical activity” is defined as energy Transportation Equity Act: A Legacy for Users spent in a normal day outside of sports, (SAFETEA-LU) will be reauthorized in 2009. exercise and recreation. This includes The legislation has been an important vehicle manual labor on the job, walking and bik- to improve federal programs that support ing to work, and household chores.304 active transportation (travel by bike, foot, or I A majority of U.S. adults (20-74 years old) other non-motorized means), safe streets, and walk less than 2 to 3 hours per week and public transportation. Researchers partially accumulate less than 5,000 steps per attribute the decline in physical activity to day.305 U.S. physical activity guidelines call how we commute to and from work. for adults to walk 10,000 steps daily. Therefore, a coalition of smart growth activists and physical activity proponents are I The automobile has significantly reduced looking at ways to use federal transportation physical activity by its frequent use for programs to boost physical activity and help short trips for shopping, going to the combat the obesity epidemic. cleaners, and other errands, and taking children to school.306 In fact, a national This coalition of advocates point to the survey found that bike lanes were avail- following facts: able for less than 5 percent of bicycle I Non-leisure time physical activity has trips, and more than one-quarter of decreased substantially in the past 20 to pedestrian trips take place on roads with 30 years due to increasing mechanization neither sidewalks nor shoulders.307 at work and in the home.303 “Non-leisure G. OTHER OBESITY RELATED LEGISLATION BEFORE CONGRESS LEGISLATION SPONSORS Nutrition & Physical Activity Federal Obesity Prevention Act of 2008, S. 3321 Sen. Tom Harkin (D-IA) This bill would amend the Public Health Service Act to provide coordinated leadership in Sen. Christopher Dodd (D-CT) Federal efforts to prevent and reduce overweight and obesity and to promote sound health Sen. Jeff Bingaman (D-NM) and nutrition among Americans, and for other purposes. The legislation requires the Sen. Edward Kennedy (D-MA) secretary of HHS to establish a Federal Task Force on Obesity to: (1) establish a Sen. Barbara Mikulski (D-MD) government-wide strategy for preventing and reducing overweight and obesity that includes defining clear roles, responsibilities, and accountability for all agencies of the Federal Government; (2) coordinate effective interagency coordination and priorities for action among Federal agencies, including short-term and long-term goals for childhood and adult obesity rates; and (3) implement and evaluate the effectiveness of such strategy. Healthy Lifestyles and Prevention America Act, S. 1342/H.R. 2633 Sen. Tom Harkin (D-IA) This comprehensive legislation requires the secretary of HHS to convene a task force on Rep. Tom Udall (D-NM) childhood obesity; allows a wellness program credit for employers; requires certain restaurants and vending machines to provide nutritional information about each food offered; provides for the development of a tool to measure community barriers to participating in physical activity and provides for grants to plan model communities of play; and provides for healthy school nutrition environment incentive grants. 77 LEGISLATION SPONSORS Nutrition & Physical Activity Improved Nutrition and Physical Activity Act (IMPACT), H.R. 2677 Rep. Mary Bono Mack (R-CA) The bill “encourages cross-sector collaborations for improving the health of young people Rep. Nita Lowey (D-NY) and ensures that community partnerships approach youth health comprehensively by addressing physical activity, nutrition and emotional wellness.”308 The bill would allow states to use preventive health and health services block grants for activities and community education programs designed to address and prevent obesity and eating disorders.309 It also requires the secretary of HHS to report to Congress on: (1) the causes and health implications of being overweight, obese, or having an eating disorder; and (2) the effectiveness of campaigns to change children’s behaviors and reduce obesity. Menu Education and Labeling (MEAL) Act, S. 2784/H.R. 3895 Sen. Tom Harkin (D-IA) The MEAL Act would amend the Federal Food, Drug and Cosmetic Act to require restaurants Rep. Rosa DeLauro (D-CT) that are a part of a chain with 20 or more locations to post calorie and other nutritional information adjacent to each food item on the menu.310 Physical Activities Guidelines for Americans Act, S. 2748/H.R. 5639 Sen. Tom Harkin (D-IA) Requires the HHS to prepare and promote physical activity guidelines based on the latest Sen. Sam Brownback (R-KS) scientific evidence, similar to the federal nutritional guidelines, commonly known as the Food Rep. Mark Udall (D-CO) Pyramid, which are updated every 5 years. Rep. Zach Wamp (R-TN) School Nutrition & Physical Education 21st Century Community Learning Centers Act of 2007, S. 1557 Sen. Chris Dodd (D-CT) This is a bill aimed at improving 21st Century Community Learning Centers. The bill identifies Sen. John Ensign (R-NV) after-school programs as effective venues for improving nutrition, nutrition education, and physical activity at a time when just 20 percent of youth in grades 9 through 12 consume the recommended daily servings of fruits and vegetables. It amends existing language (in B of title IV of the Elementary and Secondary Education Act of 1965 - 21 CCLC) to include the provision of service learning and nutrition education, and strikes current language on recreational activities and includes in its place, language on the provision of physical fitness and wellness programs. Back to School: Improving Standards for Nutrition and Physical Education in Sen. Barack Obama (D-IL) Schools Act of 2007, S. 2066 The bill codifies IOM nutrition standards into law for competitive foods and beverages sold in schools, and requires IOM to update the nutrition standard every 5 years. Additionally, schools receiving federal funding must meet standards for physical activity issued by the secretary of Education, based on standards recommended by the National Association for Sport and Physical Education. Child Nutrition Promotion and School Lunch Protection Act, S. 771/H.R. 1363 Sen. Tom Harkin (D-IA) The bill requires the USDA to update nutritional standards for foods sold outside of school Sen. Lisa Murkowski (R-AK) lunch meals so they meet current nutrition science guidelines. The bill also expands the time Rep. Lynn Woolsey (D-CA) and place rule, allowing the secretary of Agriculture to have authority over all food and Rep. Chris Shays (R-CT) beverages sold on the school campus during the school day. Fitness Integrated with Teaching (“FIT”) Kids Act, S. 2173/H.R. 3257 Sen. Tom Harkin (D-IA) This legislation would amend the Elementary and Secondary Education Act of 1965 to Rep. Ron Kind (D-WI) encourage schools to provide regular physical education and activity. It requires annual state Rep. Zach Wamp (R-TN) and local educational agency report cards to include information on school health and physical education programs and revises the professional development program for teachers and principals to include training for physical and health education teachers, and training on improving students’ health habits and participation in physical activities. Healthy Students Act of 2007, S. 100 Sen. Barbara Boxer (D-CA) The bill amends the Richard B. Russell National School Lunch Act to require the director of CDC to establish a commission to improve school meals, composed of nutrition and children’s health experts tasked with developing new nutritional standards for the School Lunch, Summer Food Service, Child and Adult Care Food, and School Breakfast programs. Requires such standards to ban foods of minimal nutritional value. 78 LEGISLATION SPONSORS School Nutrition & Physical Education Nutrition Title of the EAT Healthy America Act, H.R. 1600 Rep. Dennis Cardoza (D-CA) The bill would expand the fresh fruit and vegetable program to serve students in more schools Rep. Adam Putnam (R-FL) and instruct the secretary of Agriculture to ensure that allocation of food and food ingredients offered in school nutrition programs are based on the most recent Dietary Guidelines for Americans. Strengthening Physical Education Act of 2007, H.R. 1224 Rep. Zach Wamp (R-TN) The bill would make physical education part of No Child Left Behind’s core curriculum. The bill Rep. Ron Kind (D-WI) requires physical education assessments to begin by the 2009-2010 school year, including measurement of students’ proficiency at least one time during: (1) grades 3 through 6; (2) grades 6 through 9; and (3) grades 10 through 12. Healthy Workforce Healthy Workforce Act, S. 1753/H.R. 3717 Sen. Tom Harkin (D-IA) The bill amends the Internal Revenue Code to allow employers a 50 percent tax credit for Sen. Gordon Smith (R-OR) the costs of providing employees with a qualified wellness program. Defines “qualified Rep. Tom Udall (D-NM) wellness program” as a program that is certified by the secretary of HHS and that consists Rep. Mary Bono Mack (R-CA) of a health awareness and education component, a behavioral change component, and a supportive environment component. Terminates such credit after 2017. Requires the secretary of the Treasury to institute an outreach program to inform businesses about the availability of such wellness program tax credit. Workforce Health Improvement Program Act, S. 1038/H.R. 1748 Sen. John Cornyn (R-TX) The bill excludes from the gross income of employees the value of any on-premises Sen. Tom Harkin (D-IA) employer-provided athletic facility and fees, dues, or membership expenses paid to an Rep. Zach Wamp (R-TN) athletic or fitness facility by an employer. The value cannot exceed $900 per employee per Rep. Mark Udall (D-CO) year. It also allows employers a tax deduction for fees, dues, or membership expenses paid to an athletic or fitness facility. Built Environment Complete Streets Act, S. 2686/ H.R. 5951 Sen. Tom Harkin (D-IA) The bill ensures that “all users of the transportation system, including pedestrians, bicyclists, Rep. Doris Matsui (D-CA) and transit users as well as children, older individuals, and individuals with disabilities, are able to travel safely and conveniently on streets and highways.”311 Healthy Places Act, S. 1067/H.R. 398 Sen. Barack Obama (D-IL) The bill requires Federal agencies to support health impact assessments and take other Rep. Hilda Solis (D-CA) actions to improve health and the environmental quality of communities. The health impact assessments will include consideration of the potential health effects of land use, housing, and transportation policy and plans, including-: (a) background on international efforts to bridge urban planning and public health institutions and disciplines, including a review of health impact assessment best practices internationally; (b) evidence-based causal pathways that link urban planning, transportation, and housing policy and objectives to human health objectives; (c) data resources and quantitative and qualitative forecasting methods to evaluate both the status of health determinants and health effects; and (d) best practices for inclusive public involvement in planning decision-making. The bill also requires grants to institutions to conduct and coordinate research on the built environment and connection to health outcomes. Play Every Day Act, S. 651/H.R. 2045 Sen. Tom Harkin (D-IA) This bill requires the secretary of HHS to develop the Community Play Index to measure the Rep. Mark Udall (D-CO) policy, program, or environmental barriers in communities to participating in physical activity. Rep. Kay Granger (R-TX) The bill also requires the secretary to award grants to state health departments for work in partnership with community-based coalitions to plan and implement model communities of play. Financial Incentives Personal Health Investment Today Act, H.R. 245 Rep. Jerry Weller (R-IL) The bill amends the Internal Revenue Code to treat up to $1,000 of amounts paid annually for exercise equipment and physical exercise programs as tax deductible medical expenses. 79 H. FUNDING FOR CDC OBESITY GRANTS The proposed budget from the administra- The Coordinated School Health Program tion for FY 2009 flat-funds or cuts a number is currently available to only 22 states and of cooperative agreement grant programs one tribal government due to limited that focus on obesity prevention and health funds. Twenty states, the District of promotion at CDC, including the Division Columbia, 4 tribes and 3 territories were of Nutrition, Physical Activity, and Obesity, approved but unfunded in the latest grant the Division of Adolescent and School cycle, beginning on March 1, 2008. Health, and the Division of Adult and I Division of Adult and Community Community Health.312 Health (DACH): DACH is charged with I Division of Nutrition, Physical Activity, providing crosscutting chronic disease and Obesity (DNPAO): Through its and health promotion expertise and Nutrition and Physical Activity Program support to CDC’s National Center for to Prevent Obesity and Other Chronic Chronic Disease Prevention and Health Diseases, the DNPAO funds programs Promotion. It oversees 2 crucial pro- that use various nutrition and physical grams in the fight to prevent and treat activity intervention strategies to address obesity: the Steps Program and the obesity and other chronic diseases.313 Pioneering Healthier Communities States that are awarded DNPAO grants program. are required to create, implement and L The Steps Program funds communities monitor a nutrition, physical activity and across the country to show how local ini- obesity state plan; monitor the prevalence tiatives can reduce the burden of chron- of overweight, obesity, nutrition quality ic diseases such as obesity, diabetes, and and physical activity levels; and monitor asthma by encouraging people to be the impact of their program in changing more physically active, eat a healthy overweight and obesity related behaviors, diet, and not use tobacco.315 Steps pro- including evaluating progress and effec- grams have demonstrated progress in tiveness of their annual work plan. Under reducing obesity in community-based the new 5-year grant cycle that began in interventions; reducing chronic disease June 2008, 23 states received funding, 5 risk factors and health care costs in fewer than the previous grant cycle. workplaces; creating healthier school I Division of Adolescent and School Health environments including the provision (DASH): As part of its mission to prevent of nutritious foods and physical activity the most serious health risk behaviors enhancements; and reducing A1c levels among children, adolescents and young among diabetes patients. The Admin- adults, DASH currently provides funding istration has proposed cutting the Steps for state and territorial education agencies program by $9.6 million in FY 2009, and tribal governments to help school dis- which represents a 60% reduction for tricts and schools implement a the program over the last 2 years. Coordinated School Health Program L The Pioneering Healthier Communities (CSHP), and, through this approach, program, a partnership with CDC and increase effectiveness of policies, pro- the YMCA of the USA, addresses physi- grams, and practices to promote physical cal inactivity, poor nutrition, obesity and activity, nutrition, and tobacco-use preven- related chronic diseases in communities tion (PANT) among students.314 School across our nation. Pioneering Healthier health programs encompass health and Communities convenes action teams of physical education, school meals, health community leaders that assess local services, and healthy school environments. 80 needs and determine a local strategy for plans. Pioneering Healthier Commun- changes in schools, worksites, food dis- ities impacts 20 new communities each tribution, the built environment, and year; over 60 communities have been the community environment. CDC pro- reached since FY 2005. The Admin- vides limited funds to support commu- istration has proposed zeroing out the nity planning and implementation; con- Pioneering Healthier Communities sultation is provided throughout the program in FY 2009. planning and implementation of local FY 2009 Presidential Appropriations Request for CDC Programs and Divisions316 Division/Program FY 2008 President’s Difference in FY 2009 Funding Proposal (FY09-FY08) Division of Nutrition, Physical $42,191,000 $42,018,000 -$173,000 Activity and Obesity (DNPAO) Division of Adolescent School $54,323,000* $53,612,000* -$711,000 Health Steps to a Healthier U.S. $25,158,000 $15,541,000 -$9,617,000 Pioneering Healthier $2,900,000 $0 -$2,900,000 Communities Source: CDC Financial Management Office *Note: This includes funds for HIV programs. DASH’s Coordinated School Health Program, which deals specifically with nutrition and physical activity, was funded at $13,609,000 in FY 2008. The President’s FY 2009 budget proposal recom- mended $13,553,000 for the program. 81 A National Strategy To Combat Obesity INTRODUCTION 5 SECTION “ ALTHOUGH THE GENERAL PUBLIC HAS BECOME INCREASINGLY AWARE OF THE PERSONAL HEALTH CONSEQUENCES OF OBESITY, WHAT MAY NOT YET BE GENERALLY APPARENT IS THE PUBLIC HEALTH NATURE OF THE OBESITY EPIDEMIC AND THE CONSEQUENT NEED FOR POPULATION-BASED APPROACHES TO ADDRESS IT.317 — THE INSTITUTE OF MEDICINE (IOM) ” O besity is a genuine health crisis in this country. With approximate- ly 23 million children overweight or obese, this could be the first generation to lead sicker, shorter lives than their parents. In the past 2 decades, adult obesity rates have climbed from 15 percent to 30 percent.318 Now, two-thirds of adults are obese or overweight. Individuals are suffering major health conse- Millions of Americans have been trying to take quences, and it is costing the economy bil- personal responsibility. As a nation, we spend lions of dollars in health care and lost pro- more than $35 billion a year on weight-loss ductivity. We are failing America’s children products and services. Yet, many Americans by allowing them to develop health problems report that they struggle with paying the high- like type 2 diabetes and heart disease that will er costs of nutritious foods and the stresses of harm them for their entire lives. As a nation, working and taking care of their households we cannot have a healthy economy if we do and families, which leave little time for prepar- not have a healthy workforce. As jobs go ing healthy meals and physical activity. overseas to countries with cheaper health Clearly a strategy of personal responsibili- care, the obesity epidemic is threatening our ty alone is not working. People do not ability to compete in the global economy. make health-related or lifestyle decisions The question is what can we do about it? in vacuums. It is not the role of government to regu- Many of the forces that have contributed to late how people eat or how much they our national weight gain are deeply should exercise. ingrained in our culture, such as an increase in prepared foods and eating in restaurants, It is the role of government to remove the and the greater distances people have obstacles that get in the way of individuals between home, work, schools, and shopping making healthy choices. areas that lead to an increased need for cars It is important to challenge Americans to take and motorized transportation to get around. responsibility to be as healthy as they can be. 83 Change will not be easy. It is the role and realistically expect people to individually responsibility of government, businesses, lose significant amounts of weight in a short and communities to help individuals deal period of time and sustain that weight loss, with the forces that are beyond their con- we must avoid approaching the national trol. In fact, communities across the coun- strategy as if it were the policy equivalent of try have started taking action to try to a fad diet. This is about finding ways to address the crisis. Many states are improv- improve the health of the country for the ing the quality of school lunches; some state long term. and local governments are increasing safe The good news is that even small changes and clean parks; and farmers markets are can make a big impact. opening in some low-income communities. But this is only a start. I For individuals, a 5 to 10 percent reduc- tion in total weight can lead to positive For significant change to happen, combat- health benefits, such as reducing the risk ing obesity must become a national priority. for type 2 diabetes.323 Individual goals The country’s health and economic well- should focus on research-based solu- being require that we take action. Our lead- tions, which show health benefits from ers need to take the obesity problem seri- increasing physical activity and improv- ously and make a real commitment to help- ing the nutritional value of the foods we ing the country become healthier. eat. Weight-loss goals should focus on Over the past 8 years IOM, HHS and the realistic, incremental changes and sup- Surgeon General’s Office have all issued port strategies for helping sustain reports on the obesity epidemic in the lifestyle changes. United States.319,320,321,322 The reports have I An increase in physical activity, even with- set goals and objectives and included rec- out any accompanying weight loss, can ommendations for federal, state, and local mean significant health improvements government, community groups, business- for many individuals. A physically active es, schools, families, and individuals to lifestyle plays an important role in pre- help meet them. Despite these high-level venting many chronic diseases, including calls to action, there is little evidence of coronary heart disease, hypertension, any national framework to respond to the and type 2 diabetes.324,325,326,327 obesity epidemic. I For the country, community efforts to TFAH calls on the country’s leaders to create reduce obesity and increase physical activ- a National Strategy to Combat O besity. This ity can have a significant health and mon- needs to be a comprehensive, realistic plan etary return on investment. that involves every agency of the federal gov- ernment, state and local governments, busi- A Nat ional St rat egy t o Combat O bes it y nesses, communities, schools, families, and must include: individuals. It must outline clear roles and A. Federal government, involving presiden- responsibilities and demand accountability. tial and Congressional leadership, every Our leaders should challenge the entire Cabinet department, adequate funding, nation to take responsibility and do their part and clear performance measures. to help improve our nation’s health. B. State government. As a primary goal, the Nat ional St rat egy t o Combat O bes it y should aim to reduce the C. Local government. childhood obesity epidemic by 2015. D. Community and faith-based organizations. A turnaround will not happen overnight. E. Schools. The same way research has shown we cannot 84 F. Families and individuals. TFAH has also identified some special topics (Section L) that must receive increased atten- G. Employers. tion as part of a National Strategy, including H. Insurers. racial and ethnic disparities, rural childhood obesity, and mental health, stress and obesity. I. Food and beverage industries. The components of the Nat ional St rat egy J. Agribusiness and farmers. t o Combat O bes it y are based on the evi- K. Health researchers and evaluators. dence cited throughout this report. GETTING STARTED “ SUCCESS “MAY TAKE SEVERAL YEARS OR DECADES AND REQUIRE THE SUSTAINED AND COORDINATED IMPLEMENTATION OF A COMPREHENSIVE AND INTEGRATED SPECTRUM OF STRATEGIES AND ACTIONS TO PRODUCE THE NECESSARY CHANGE IN A VARIETY OF OUTCOMES -- INCLUDING STRUCTURAL, INSTITUTIONAL, SYSTEMIC, ENVIRONMENTAL, BEHAVIORAL, AND HEALTH OUTCOMES.328 — INSTITUTE OF MEDICINE (IOM) ” TFAH calls upon the next president to make To help outline how different agencies obesity prevention and control a priority of impact obesity and why a federal govern- his administration. Within the first 3 months ment approach is necessary, TFAH has of taking office, the president should con- conducted a review of federal government vene a sub-cabinet working group to address programs and policies (See Appendix C: the issue. In the past, health officials often Over view of Federal Programs That have been called on to develop solutions in Impact Obesity). isolation. There are many factors, however, A Nat io nal St rat egy t o Co m bat O bes it y that are beyond the ability of health officials will work best with strong leadership from to influence by themselves. In addition, the the president and Congress, goals and ramifications of the obesity crisis impact the strategies outlined by health experts, and nation’s economy and global standing. A coordination of all of the different new model must address obesity across every Cabinet agencies to leverage all of the gov- sector of the government. The National ernment’s resources. Therefore, the sub- Strategy for Pandemic Influenza Planning cabinet working group will consult regu- provides a strong example for how this type larly with an Obesity Prevention Advisory of effort can be undertaken. With leadership Board made up of representatives from and goals identified by health agencies and state and local government, schools, com- experts, every cabinet agency has taken munity and religious groups, business, charge of developing and implementing poli- including the food and beverage industry cies and programs in their jurisdiction that and farmers, insurance companies, and all contribute to our nation’s preparedness researchers and scientists. for a pandemic flu outbreak. 85 A. FEDERAL GOVERNMENT “ FIRST AND FOREMOST THE GOVERNMENT PROVIDES LEADERSHIP, WHICH IT DEMONSTRATES BY MAKING THE RESPONSE TO THE OBESITY EPIDEMIC AN URGENT PUBLIC HEALTH PRIORITY AND COORDINATING THE PUBLIC- AND PRIVATE-SECTOR RESPONSE.329 JUST AS IT HAS DONE WITH AUTOMOBILE AND HIGHWAY SAFETY INITIATIVES, EFFORTS TO CURB YOUTH SMOKING, AND CURRENT EFFORTS TO DEFEND AGAINST POTENTIAL BIOTERRORIST THREATS, THE FEDERAL GOVERNMENT SHOULD SET FORTH OBESITY PREVENTION AS A NATIONAL HEALTH PRIORITY - ONE THAT IS ACTED UPON THROUGH EXTENSIVE AND SUSTAINED FUNDING AND A LONG-TERM COMMITMENT OF RESOURCES.330 ” — INSTITUTE OF MEDICINE (IOM) The federal government has the unique ability In addition, the federal government can to set priorities and bring together state and institute policies and programs that give local governments, the private sector, and com- Americans the tools they need to make it munities to work towards solutions. The feder- easier to engage in the recommended al government has the leadership position to be levels of physical activity and choose able to develop and set goals for implementing healthy foods. a National Strategy to Combat O besity . 1. Presidential and White House Leadership As the leader of the country, the president has need to work together to put substantial the most important role to play in the resources behind the National Strategy to National Strategy to Combat O besity . Combat O besity . This requires an honest assessment from all federal government I Acknowledge That Obesity is a National departments and agencies regarding their Priority responsibilities under the plan and the L The president must take responsibility for resources they will need to fully implement ensuring the future health of the country. and evaluate their programs. Funding The president must lead the movement to must also come from state and local gov- make the United States a country that ernments to address this shared responsi- encourages and fosters healthy living by bility. The funding must include an invest- supporting policies that remove the obsta- ment to increase both scientific research to cles that get in the way of individuals mak- develop effective, wide-scale public health ing healthy choices. solutions and to provide communities with the capacities and resources needed to I Ensure Sufficient Funding to Implement make changes. The federal government and Evaluate Obesity Policies needs to make a serious national commit- L If the U.S. is serious about reversing the ment to this public health crisis. obesity trend, the president and Congress 86 FEDERAL FUNDING FOR OBESITY-RELATED PROGRAMS “There is a marked underinvestment in the prevention of childhood obesity and related chronic diseases.”331 — Institute of Medicine (IOM) Despite the numerous government reports federal funding for nutrition, physical activity, on the worsening obesity epidemic and vari- and obesity programs has remained virtually ous studies showing the economic burden of flat over the past 3 years for 2 major pro- obesity on government and the private sector, grams and declined sharply for a third. Source: CDC’s Financial Management Office, Budget Requests for FY2005 through FY2009. Available online at http://www.cdc.gov/fmo/fmofybudget.htm. As noted previously, DASH funding is primarily for HIV prevention activities and not obesity-related programs. I Communicate that Reversing the Obesity L The president should appoint a secretary of Epidemic is a National and Government- HHS who shares a vision that focuses on wide Priority reversing the obesity epidemic and foster- L The president should require all federal ing a healthy environment, not solely on departments and agencies to consider treating the problems of obesity after it has the impact on physical activity and nutri- become a problem, and who will organize tion of all major policy initiatives. and strengthen HHS. L The president should convene a sub-cabinet L The president should ensure that health sys- working group on government-wide tem reform proposals consider the integra- approaches to combating key public health tion of public health and prevention. problems, like obesity. The working group L The president should direct federal agen- would report to the president or the White cies to coordinate a nationwide public House chief of staff through the assistant to education campaign that highlights men- the president for domestic policy. tal and physical health as a combined L The president should establish an Obesity entity and encourages people to be as Prevention Advisory Board to consult with healthy as they can be. The campaign the sub-cabinet working group on the devel- should include messages regarding stress opment of the National Strategy to and stress reduction given the association Combat O besity . The advisory board would between poor health outcomes, includ- also serve as a watchdog over federal obesity ing obesity, and high levels of stress. prevention and control efforts and set short- and long-term goals on obesity issues. 87 2. Obesity-Prevention as a Priority Across All Cabinet Departments “ OBESITY PREVENTION IS A CROSS-CUTTING ISSUE THAT DOES NOT NATURALLY FALL UNDER THE PURVIEW OF ANY ONE FEDERAL DEPARTMENT.332 — THE INSTITUTE OF MEDICINE (IOM) ” Addressing obesity should not be viewed as Upon the completion of such a review, each the sole responsibility of HHS. Instead, it is agency should propose ways it can partici- something in which all federal agencies pate in and implement aspects of the should participate. In fact, while HHS National Strategy to Combat O besity . shoulders a large burden of the costs of obe- sity-related treatments and illness as borne I Designate High-Level Officials in Each by Medicare and Medicaid, the agency is just Department to Address Obesity one of many federal agencies with an impor- L The president should order the designa- tant role to play in the obesity fight. tion of an official in each cabinet depart- ment who focuses on obesity-related poli- Instead, much of the implementation of cur- cies. The official would work within each rent obesity and physical activity initiatives department to examine the implications occurs in other cabinet departments, such as of policies and activities -- from agricul- the U.S. Departments of Agriculture, ture to transportation -- on obesity. Education, Housing, Interior, and Transportation. (See Appendix C: Overview of I Health Impact Assessments Federal Programs That Impact Obesity.) L The president should require that feder- HHS, however, plays an essential role in pro- al departments and agencies evaluate viding technical and policy leadership on and report on the health impact, particu- obesity as a health issue, and funding larly the impact on physical activity and research into effective interventions. nutrition, of new domestic policies, pro- grams, and annual budgets. Many TFAH recommends the following actions to European jurisdictions employ similar improve cross-government collaboration: processes and several U.S. localities, such I Federal Government Review as Seattle-King County in Washington L With the president’s support and encour- State, Tri-County in Michigan, Hennepin agement, federal agencies should under- County in Minnesota, Riverside County take a detailed review of their programs and and San Francisco in California, have budgets and examine how they impact recently adopted this approach. physical activity, nutrition, and obesity. THE IMPACT OF NEIGHBORHOODS ON OBESITY The U.S. Department of Housing and Urban impact of the move on a number of variables, Development’s (HUD’s) Moving to including obesity on the assumption that Opportunity (MTO) program provided thou- “moves to low-poverty neighborhoods may sands of poor adults and children an opportu- reduce obesity through several mechanisms: nity to use HUD vouchers to move out of lower incidence of depression and stress; public housing in high poverty neighborhoods behavioral changes (like exercise); and differ- to lower poverty neighborhoods. The 10- ent social norms about eating habits.”333 The year demonstration project ran from 1992- evaluation found that obesity rates fell among 2002. A HUD evaluation examined the adults and children in the MTO program.334 88 I Worksite Wellness for Federal Employees ter public health awareness among L The president should establish a pro- employees. This approach will serve as an gram that can assist federal employees in important model for the private sector. achieving healthy lifestyles as well as fos- OVERWEIGHT AND OBESITY IN THE MILITARY A 1992 IOM report “Body Composition and often discharged. In fact, every year Physical Performance: Applications for the between 3,000 and 5,000 enlisted members Military Services” noted that “obesity is associ- are forced to leave the military for being ated with being unfit and ‘un-soldierly.’”335 overweight.339 A 1995 Defense Department Military recruiters dismiss volunteers based study estimated the average cost of recruit- solely on height and weight before entering ing and training a replacement enlisted mem- the service on the presumption that they are ber to be $40,283, or $56,782 in 2008 infla- not physically fit enough to enlist, train, and tion-adjusted dollars.340,341 This costs the serve. Perhaps unsurprisingly, the obesity epi- Department of Defense between $170 mil- demic that is affecting the general U.S. popula- lion and $284 million a year and does not tion is also posing problems for the U.S. mili- include additional obesity-related medical tary. Among new military recruits the per- expenses. A separate 2007 study estimated centage of overweight and obesity among 18- that the U.S. military healthcare system, TRI- year old civilian applicants increased from 25.6 CARE, spends $1.1 billion annually to treat percent in 1993 to 33.9 percent in 2006.336 overweight- and obesity-related diseases.342 The problem is not limited to new recruits. To combat the growing obesity problem According to a U.S. military spokeswoman, 16 among U.S. servicemen and women, each of percent of active duty personnel are obese.337 the armed services has developed programs Some branches of the military are more affected to promote fitness and health: the Army has than others. For instance, the U.S. Navy reports Weigh to Stay; the Navy and Marine Corps that 62 percent of its members are overweight have ShipShape; the Air Force has Fit to and 17 percent are obese, while the U.S. Air Fight. These programs use nutrition and fit- Force reports that 55 percent of airmen are ness counseling to move military personnel overweight and nearly 12 percent are obese.338 and their families toward healthier food choices, exercise habits, and lifestyles. Service members who exceed height-weight guidelines for their branch of the military are TFAH recommends the following federal- cies should be viewed as setting a floor for level actions to prevent and control obesity. action to combat obesity and not a ceiling, The following recommendations should not meaning that state and local governments be seen as a comprehensive list of federal should be empowered to take more dramat- policy actions, but a starting point for gov- ic action when possible. ernment action. At all times, federal poli- 89 3. Federal Government and Schools Nutrition Policy ing physical activity with academic per- I USDA should issue revised school nutri- formance there is an added incentive to tion guidelines that ensure that American mandate physical activity. schoolchildren are consuming foods rec- I The administration and Congress should ommended in the most recent Dietary review the Department of Education’s 21st Guidelines for Americans (DGAs). Century Community Learning Centers and Although it has been 3 years since the consider an expansion of their mission to release of the 2005 DGAs, USDA has been include physical activity, health, nutrition unable to develop new guidelines. If the counseling, and nutrition activities. current timetable holds, new guidelines are not expected until 2010 at the earliest. I The administration and Congress should review the Department of Education’s Carol Physical Education & Activity Policies M. White Physical Education Program, and I The U.S. Department of Education, in consider an expansion of the federal grant collaboration with HHS and the program so that more local educational President’s Council on Physical Fitness, agencies and organizations can participate should set national standards for physical and work to initiate, expand, and improve education and physical activity in schools. physical education programs for students. Given the growing body of evidence link- THE PRESIDENT’S CHALLENGE ADULT FITNESS TEST In an effort to get adults to be more active, test to assess overall health: a one-mile walk the President’s Council on Physical Fitness or 1.5-mile run to gauge cardiovascular fit- and Sports introduced the adult fitness test in ness, one minute of half sit-ups and push-ups May of 2008. According to Melissa Johnson, to failure to determine strength, and the sit- the executive director of the council, “what and-reach exercise to measure flexibility.344 we are trying to do is inspire and motivate Individuals are encouraged to visit the adult fit- Americans to move their bodies more.”343 ness test website at www.adultfitnesstest.org The test includes 3 basic components of to learn more about the test as well as record health: aerobic fitness, muscular strength results and receive an evaluation. and flexibility. Each component contains a 4. Federal Government and Business I Be Model Employers wellness programs and preventive care L Government agencies should set an coverage to their employees. example for private businesses and I Update and Increase Obesity-Related organizations by placing a priority on Coverage employees’ health and assure compre- hensive benefits for obesity within the L Medicare, Medicaid, and SCHIP should Federal Employee Health Benefit Plan. update and increase obesity-related cover- age and reimbursement for preventive I Incentivize the Private Sector to Provide services (e.g. nutrition counseling and Wellness Programs physical activity programming) and set an L Federal, state, and local governments example for private insurers. (See Section 3: should find ways to incentivize or encour- State Responsibilities and Policies for a detailed age employers to provide workplace legal analysis of current state insurance policies.) 90 5. Federal Government and the Food and Beverage Industries I Work with Industry to Limit Advertising I Work with Industry on Portion Size and to Children Labeling L The Federal Trade Commission (FTC), L FTC, the Food and Drug Administration Department of Commerce, and HHS (FDA), USDA, Department of Commerce, should convene a national summit of and other relevant federal agencies should food, beverage, and confectionery com- work with industry and retail outlets to devel- panies to discuss voluntary restrictions on op clear and useful nutrition labeling and to marketing and advertising of unhealthful ensure that packaged foods and meals foods to children and youth. These reflect the recommended portion sizes. measures would apply to television and Retail food outlets in particular are routinely radio advertising and newer media, selling meals that are 2 to 3 times larger than including internet, video gaming, DVDs, what food labels list as a serving.345 and other non-traditional means of advertising. If voluntary measures do not I Require Retail Food Outlets to Provide go far enough, the federal government Menu Labeling should pursue regulatory action to limit L FDA, USDA, Department of Commerce, advertising and marketing as was done and other relevant federal agencies with the tobacco manufacturers. should work with retail food outlets to provide better and more readily accessi- L The Department of Education should ban ble information about the nutritional all marketing and advertising of unhealthy content of their products. If voluntary foods in schools. This includes: agreements do not work, regulatory • Advertising on Channel One, a news approaches should be considered. and public affairs content provider to many high schools and middle schools, I Remove Barriers to Breastfeeding L HHS should work with hospitals and health • Product sales, through vending machines, care providers and food industry represen- soft drink “pouring rights” agreements, tatives to broker a voluntary agreement to branded fast food, and fundraisers; halt free infant formula distribution at hos- • Indirect advertising, such as corporate- pitals to encourage breastfeeding. An eval- sponsored educational programs, sports uation of the voluntary ban should guide sponsorships, and incentive programs future decisions to continue the voluntary using contests and coupons. ban, and perhaps, make it binding. 91 6. Federal Government and Agriculture I Examine Subsidies for Growing Fruits syrup and vegetable oils declined. USDA and Vegetables should study the factors behind this dis- L Congress and the administration should crepancy and offer policy solutions to evaluate farm policy and eliminate barri- make it economically viable for ers to the domestic production of fruits Americans to buy fresh produce. Policy and vegetables. A major barrier to their solutions include the following: production is the government subsidies • Funding and technical advice for city res- for corn, wheat, soybeans, rice, and cot- idents interested in planting and tending ton which range from $10 billion to $25 urban fruit and vegetable gardens. billion a year. • Financial and logistical support for farmers markets. I Support Small Farmers and Local Food Systems • Re-directing commodities subsidies to fruit and vegetable growers. L USDA should support farmers markets, farm-to-school, urban gardens, and other I Revise School and Government programs that bring fresh, locally grown Procurement Policies food into communities, especially those L USDA should reexamine its child nutri- that are underserved by major grocery tion programs and ensure that they stores. By providing consumers with encourage the consumption of healthy greater choice the government can help foods, including the recommended daily create demand for locally grown fresh amount of fruits, vegetables, and whole produce and incentivize the return of grains. By setting higher nutritional stan- small farms to this market. dards, or expanding food assistance pack- I Incentivize Healthy Food Consumption ages to include more produce (as was done with WIC), USDA can increase the L According to USDA’s Economic Research demand for fresh fruits and vegetables Service the cost of fresh fruit and vegeta- and ensure a market for farmers who bles rose 40 percent between 1985 and produce these goods. 2000, while the cost of high-fructose corn 7. Federal Government and Research I Strengthen Primary Data Collection is going on in their environments. As the Systems 2007 IOM report on childhood obesity L Researchers and public health practition- notes, “surveillance is particularly lacking ers need better data. A strong national regarding the environmental and institu- surveillance system is crucial to assess tional changes that are being implement- Americans’ health. The federal govern- ed with the goal of promoting healthful ment must renew and deepen its invest- eating and regular physical activity.”346 ment in the National Center for Health I Fund Community-Level Research and Statistics, specifically in the National Evaluation Health and Nutrition Examination Survey (NHANES), the National Survey L According to the IOM report “Progress in on Children’s Health, the Behavior Risk Preventing Childhood Obesity”, “the gap Factor Surveillance System, and others. between the opportunity for evaluations and the capacity to conduct evaluations at L Researchers need better data on chil- the local level appears to be a significant dren, particularly children in the 5 to 14- impediment to the identification and years age group. They need to know what widespread adoption of effective child- 92 hood obesity prevention programs.”347 To • Government agencies and research address the lack of local-level program institutions should offer technical assis- evaluation, TFAH echoes IOM’s recom- tance to local community groups. mendations, which include the following: • Government agencies and local govern- • Local program managers should receive ment/community groups should com- funding specifically to carry out pro- municate frequently about on-the- gram evaluations in partnership with ground success stories. colleges, universities, or other commu- nity groups with expertise. B. STATE GOVERNMENT “ OF COURSE, PERSONAL RESPONSIBILITY IS A CRUCIAL PART OF ANY SOLUTION, BUT GOVERNMENT AND GOVERNORS ALSO HAVE AN IMPORTANT ROLE.348 — NATIONAL GOVERNORS ASSOCIATION (NGA) ” In the campaign to stop and prevent obesity, tives, including objectives that are related to the role of the state government is similar in reducing obesity rates; link state funding to many ways to the role of the federal govern- objectives; include private sector and com- ment. States should provide top-level leader- munity groups; contain provisions for a ship on this issue and devote more resources healthier state workforce; and incorporate -- both financial and manpower -- towards a system for evaluation and review. (See combating the problem. States, however, are Section 3: State Responsibilities and Policies for a closer to the action on the ground and can discussion of current state obesity plans.) direct focused efforts towards the problem. I Evaluate Their Roles and Delegate Development of the Nat ional St rat egy t o Responsibilities Among State Agencies Combat O bes it y should occur with state L Similar to the federal review and with the and local input, reflecting the shared support of each state’s governor, state responsibility of all jurisdictions for the agencies should undertake a review of health of Americans. In parallel with the their programs and examine how they development of the national strategy, states impact physical activity, nutrition, and obe- should: sity. Upon the completion of such a review, I Develop State-Specific Obesity Plans each agency should propose ways they can L Using best practices put forth by CDC and participate in and implement aspects of based on the most up-to-date scientific evi- their state’s strategic obesity plan. dence, states should develop their own I Dedicate State Revenues to Implementing plans to combat obesity using policy and the National Strategy to Combat Obesity environmental changes. These state-level plans should be tailored to meet individual L The National Strategy to Combat O besity states’ needs and use culturally competent will also require states to contribute to fund- strategies to engage various communities ing obesity prevention efforts. Federal and within the state. These plans should: state governments should undertake an involve multiple state agencies; assign spe- assessment to determine how much each cific roles and responsibilities to state agen- state should be required to contribute in cies; contain clear and measurable objec- order to qualify for federal funds. Different 93 states have different needs. Some states I Update and Increase Obesity-Related have a higher burden of obesity and obesi- Coverage ty-related diseases, and therefore, a higher L State Medicaid and SCHIP programs level of investment may be needed to should update and increase obesity-relat- achieve goals for improving the health of ed coverage and reimbursement for pre- people in those states. An investment by ventive services (e.g. nutrition counseling states will also show a commitment by the and physical activity programming) and state government to improving health. As set an example for private insurers. the 2007 IOM report on childhood obesity L States should also assess their insurance noted, “the overall capacity to address child- regulations to assure equitable access to hood obesity is not enhanced when increas- health insurance for those who are obese es in federal funding are responded to by or overweight and to assure adequate cov- decreases at the state level. A sustained erage for treatment and services directly effort that includes adequate planning and related to obesity. (See Section 3: State cooperation is needed among governmen- Responsibilities and Policies for a detailed legal tal agencies and departments and other analysis of current state insurance policies.) stakeholder groups at these levels to effec- tively work together.”349 I Leverage Power as Food Purchaser I State Government Employee Wellness L The state public sector purchases food Efforts across a range of institutions, including in government cafeterias, schools, and prisons. L State and local governments are employers The government should leverage its power as well as providers of governance and pub- as a food purchaser to require a greater lic service. Many governors have begun emphasis on nutritional value as a priority in initiatives to provide workplace wellness the bidding process for these contracts. and preventive health care services, includ- ing: premium discounts, subsidies for I Create Healthy Schools fitness clubs and activities, disease manage- L The state departments of health and edu- ment programs, and information to state cation should work together to implement employees, such as nutrition, physical a coordinated school health program to activity, and obesity counseling. All states create a healthy school environment. should offer these programs and should also provide these models to private I Evaluate Current Snack Tax and Liability businesses to expand these opportunities Limitation Policies to private employees as well. L States should devote time and resources L State and local government should also to developing evaluation standards to assure that their state employee health monitor the effectiveness of both types of insurance plans cover appropriate obesi- controversial initiatives. ty-related services. THE NATIONAL GOVERNOR’S ASSOCIATION HEALTHY STATES PROGRAM The National Governor’s Association (NGA) ages governors to focus their efforts in 3 areas: has made obesity prevention a priority since communities, worksites, and schools.350 2002 even establishing a bi-partisan taskforce of The report highlights best practices from var- governors to provide leadership on this issue. ious states around the nation in order to fos- NGA focuses on promoting a culture of well- ter the exchange of ideas and success stories ness to improve Americans’ health and thus among governors and state officials. By high- increase our global competitiveness and lower lighting what works, NGA hopes to encour- health care costs. NGA’s report Creating age more state action to promote wellness. Healthy States: Actions for Governors encour- 94 NGA’S HEALTHY KIDS, HEALTHY AMERICA INITIATIVE The Healthy Kids, Healthy America program change, and up to $10,000 can be used to awards states funding for childhood obesity conduct a statewide scan of current efforts prevention programs and statewide scans, or within their state to prevent childhood obesity. reviews, of existing efforts. As of April 2008, The 2008 recipients are: Indiana, Kentucky, 15 states have been awarded up to $110,000 Louisiana, Michigan, Minnesota, Mississippi, to fund their childhood obesity prevention New Mexico, New York, Rhode Island, programs. Of that sum, up to $100,000 can be South Dakota, Tennessee, Utah, Virginia, used to fund proposals to prevent childhood West Virginia, and Wisconsin. obesity through environmental and policy C. LOCAL GOVERNMENT “ LOCAL GOVERNMENT PLAYS A COMPLEMENTARY ROLE TO STATE AND FEDERAL OBESITY PREVENTION EFFORTS. IN PARTICULAR, LOCAL PUBLIC HEALTH DEPARTMENTS ARE INVOLVED IN PROVIDING LEADERSHIP FOR THE HORIZONTAL INTEGRATION OF INTERVENTIONS, COMMUNICATIONS, AND FUNDING REQUIREMENTS, AS WELL AS DEVELOPING ADEQUATE INFRASTRUCTURE FOR POLICIES AND PROGRAMS TO BE IMPLEMENTED AND EVALUATED AT LOCAL LEVELS.351 — INSTITUTE OF MEDICINE (IOM) ” Local government and community groups retail food regulations. The environment often have the strongest direct impact on peo- that surrounds people has a large effect on ple’s health, and the National Strategy to individual choices, including the following: Combat O besity must rely on these groups to I A 2003 study found that suburban sprawl is implement programs and make positive linked to health. Not only are people in changes to the built environment. This will more sprawling communities likely to have a require strong leadership from local health higher BMI, but they are also at increased officials and the ability of these officials to risk of suffering from hypertension or high communicate the importance of physical blood pressure. Based on the findings of the activity and nutrition to their communities. study, people in the most sprawling areas are Experts should evaluate how local govern- likely to weigh 6 pounds more than those in ments can or should help fund wellness, obe- the most compact communities.352 sity, and physical activity programs. For many I A 2008 study found that people who live local programs, relying on the local property near an abundance of fast food restaurants tax base, for instance, can lead to exacerbat- and convenience stores are significantly ing pre-existing disparities among neighbor- more likely to suffer from obesity and dia- hoods. As with many social issues, the lowest- betes when compared to people living income areas are the hardest hit by obesity near grocery stores and famers’ markets.353 and obesity-related health problems. Americans are interested in and support the Local government can act -- and act decisive- idea of healthy communities. One study ly -- in the area of the built environment and 95 found that 90 percent of U.S. adults support I Examine Health Impact of New Building using local government funds for walking and L Communities should require “Health jogging trails, recreation centers, and bicycle Impact Assessments” for proposed land-use paths.354 Another study reported that 55 per- and building projects, which will help com- cent of Americans would like to walk more munities and policy makers understand and drive less, and 52 percent would like to the possible resulting changes to people’s bicycle more.355 It appears that the demand is health, including access to recreational there for communities to invest in building space and to food shopping. These can be bike paths and walking and running trails. based on the “Environmental Impact Local government plays a key role in chang- Assessment” model. ing the built environment so that it fosters I Building Design Codes healthy eating and healthy lifestyles. From issues related to zoning and public trans- L Encourage new building design that is stair- portation, to funding for community-based friendly and offers other spaces that facilitate programs, local officials lead the way. activity in commercial and public buildings. As part of the Nat ional St rat egy t o Combat I Encourage Greenspace Development O bes it y , local governments should: and Build More Sidewalks L Prioritize and incentivize increased I Provide Improved Access to Healthy greenspace development through the Foods in Low-Income Areas collaboration of public health and trans- L Healthy food access is a demonstrated portation entities in states. Communities problem in many low-income communi- should also place greater emphasis on ties. Communities should encourage the building well-lit sidewalks and paths, par- development of and provide public space ticularly in new developments and for locally-operated produce markets and around highways, to make it possible for farmers’ markets. Also, through the use of people to walk safely. incentives, communities should encourage supermarkets and food shopping vendors I Encourage Transportation Fund Use for to locate in lower-income neighborhoods Mass Transit and Alternatives to Highways and offer healthier food alternatives. L Communities should insist that states and counties require alternative proposals be I Use Zoning Laws to Change Food examined when new highway initiatives are Environment proposed. New development should also L Zoning laws can be used to encourage be required to include pedestrian-friendly healthy food providers to locate to under- components, such as sidewalks, which served neighborhoods; local government encourage interconnectivity of communi- can also implement zoning laws to limit ties and opportunities for activity. State fast-food restaurants or keep a certain and federal transportation dollars should ratio of fast food restaurants to grocers be considered for mass transit, sidewalk, and farmers’ markets. and mixed use opportunities rather than I Encourage “Mixed Use” Areas be focused on highway construction. L Communities and states should examine I Modernize New School-Site Construction and update zoning and land-use laws to Requirements allow for more “mixed use” commercial L Local governments should review and and residential communities, so people update old acreage requirements for new can have more opportunities to walk or school construction that required large bike to retail centers and to work. spaces for construction, but have ended up resulting in the building of schools in 96 remote locations that students can often nomic investment. Many of these centers only access by bus rather than by walking have the necessary attributes to make or biking. Flexible standards for school them walk-able and bike-able communi- site construction would allow communi- ties. Local governments should invest in ties to build schools closer to existing revitalizing old downtowns and occupy- homes and commercial regions instead ing vacant buildings and lots. of in remote areas. I Require Menu Labeling I Revitalize Walk-able Neighborhoods L Local governments should require restau- L Many cities and towns have downtown rants to provide consumers with nutrition areas that were at one time vibrant eco- information on in-store menus and menu nomic centers, but have since lost eco- boards for the most popular items. HEALTH IMPACT ASSESSMENT OF MENU LABELING In 2008, the Los Angeles County Department an average reduction of 100 calories per of Public Health conducted a health impact meal, no increase in other food consumption, assessment of menu labeling. County health and no increase in physical activity. Based on officials were interested in determining the this assumption the researchers found that effect of menu labeling on the obesity epi- menu labeling would prevent nearly 40 per- demic. Researchers used the conservative cent of the estimated 6.75 million pounds assumption that nutrition labeling would that Los Angeles County residents age 5 and result in 10 percent of chain restaurant cus- older gain in weight each year.356 tomers ordering reduced calorie meals, with EXAMPLES OF LOCAL GOVERNMENT OBESITY-RELATED POLICY FIXES New York, NY -- In January 2008, New Seattle, WA -- Active Seattle, a partnership York City’s Board of Health issued a regula- under Active Living by Design, is one of tion requiring all restaurants that operate at many cities seeking to create walk-able least 15 separate outlets to post calorie neighborhoods.360 Seattle chose 5 communi- counts on their menus and menu boards. ties to implement the design. Some pro- The new regulation will affect about 10 per- gram accomplishments include: cent of all New York City restaurants.357 I Implementation of a Safe Routes to New York City had passed similar legislation School program at 2 elementary schools. in 2006 but a U.S. district judge rejected the measure on grounds that it violated federal I Completion of 10 walking audits in proj- food-labeling laws. Although the State ect area neighborhoods as part of the Restaurant Association continues to chal- assessment process. lenge the regulation in court, on May 5, I Generation of over $494,000 in grants and 2008 the City Health Department started contributions for Safe Routes to Schools. issuing citations to chain restaurants that were not in compliance. Fines will not be I Advocating successfully for $875,000 in assessed until July.358 Similar legislation has spending for sidewalks and stairways in been enacted in San Francisco and the mayor’s budget, and generated an Seattle/King County, Washington, and is addition $1.8 million supplemental funding under consideration by 21 other state and for sidewalks and crossings. local governments.359 97 THE GROCERY GAP Residents in low-income and minority neigh- from 900 to 69,000 square feet. These proj- borhoods are less likely to have access to ects are expected to bring 3,723 jobs and fresh fruits and vegetables than people who 1.2 million square feet of fresh food retail to live in higher-income and predominantly communities across Pennsylvania.366 white neighborhoods.361 Large supermar- New York, NY -- New York City has lost kets, which have a better selection of fresh one-third of its supermarkets over the past produce and other healthy foods, such as 6 years severely limiting lower-income resi- whole grains and lean proteins, tend to be dents’ access to fresh, healthy foods.367 In missing from low-income and minority com- early 2008, the City Council voted in favor munities across the United States. of a measure designed to increase the num- According to The Food Trust, a Philadelphia- ber of fruit and vegetable carts in under- based organization whose mission is to served neighborhoods.368 The measure will ensure that everyone has access to afford- put up to 1,000 produce vendors on the able, nutritious food, the so-called “‘grocery streets in 43 different police precincts. The gap’ existing today in many urban areas bill was opposed by members of a smaller resulted from the confluence of complex grocers’ association on the grounds that social, economic and public policy factors.”362 these push cart vendors would take business When middle class whites left big cities in away from them while not actually increas- the 1960’s and 1970’s for the suburbs, the ing demand. City officials justified the meas- large supermarkets often followed, attracted ure by citing a 2006 New York City health by larger, less expensive commercial tracts department survey that found that just 20 of land, business-friendly zoning, and less percent to 40 percent of smaller grocers, or crime.363 In the place of supermarkets, low- bodegas, carried apples, oranges and income and minority neighborhoods have bananas, while fewer than 6 percent stocked seen an influx of small grocers, convenience leafy green vegetables. stores and fast food restaurants.364 These New Orleans, LA -- In 2007, the New retail food outlets are less likely to sell fresh Orleans Food Policy Advisory Committee produce and other healthy food options. published a 24-page report detailing the chal- Researchers suggest the lack of healthy fresh lenges faced by many residents of southern foods coupled with the glut of unhealthy Louisiana after Hurricanes Katrina and Rita. food choices contributes to the high rates of According to the report, the storms drasti- obesity, diabetes, hypertension, and cardio- cally reduced the number of food retailers vascular disease among low-income and serving the public at a time when there was minority populations.365 To counter these already a deficit of these outlets.369 negative effects, a number of organizations, Currently, there are only 15 supermarkets in such as the Food Trust, are working with New Orleans, a city where public trans- local officials to increase consumers’ access portation is still unreliable and one-quarter of to fresh produce and healthier food options. residents don’t have cars.370 The Committee made a number of recommendations for city Pennsylvania -- The Philadelphia-based and state officials to remedy the problem, Food Trust was instrumental in launching the including the provision of grants and loans to Pennsylvania Fresh Food Financing Initiative small grocers and supermarkets. Large (FFFI), a first of its kind program in the supermarkets, however, are wary of opening United States that uses state and private shop in New Orleans due in part to the dev- funds to bring supermarkets carrying a vari- astation wrought by the 2005 hurricanes and ety of healthy food into underserved low- the lack of a local distribution network. income, minority neighborhoods in an According to one supermarket manager, it is attempt to improve eating habits and overall a 14-hour round trip to his nearest distribu- health. As of January 2008, the FFFI had tor; few supermarkets are willing to pay committed $38.9 million in grants and loans those kinds of transportation costs.371 to 50 stores across the state, ranging in size 98 D. COMMUNITY AND FAITH-BASED ORGANIZATIONS “ BY STEPPING OUTSIDE THE TRADITIONAL VIEW OF OBESITY AS A MEDICAL PROBLEM, WE MAY MORE FUNDAMENTALLY FOCUS ON THE MANY INSTITUTIONS, ORGANIZATIONS, AND GROUPS IN A COMMUNITY THAT HAVE SIGNIFICANT ROLES TO PLAY IN MAKING THE LOCAL ENVIRONMENT MORE CONDUCIVE TO HEALTHFUL EATING AND PHYSICAL ACTIVITY.372 -- THE INSTITUTE OF MEDICINE ” Although prevailing U.S. public opinion is L Community and faith-based groups that obesity is an individual’s problem, the should reach out to their members using reality of the epidemic is that it is often a culturally-competent messages promot- community’s problem. Communities are ing healthy nutrition and physical activity. affected when there are no easily accessible grocery stores nearby. Communities are I Provide Opportunities for Safe and affected when crime and violence prevent Supervised Activity for Children children, youth, and adults from engaging L Community and faith-based groups should in outdoor physical activities. develop and support organizations and Communities are affected when unemploy- facilities that allow children to participate ment rates are high and access to health in safe physical activity programs. care is limited. Thus, community-based and faith-based organizations have an I Provide No- or Low-Cost Physical Activity important role to play in the Nat io nal Opportunities and Nutrition Counseling St rat egy t o Co m bat O bes it y . L Community and faith-based groups should support no- and low-cost venues Community and faith-based organizations for children and adults to participate in can also help public health and local gov- physical activity. They can do so by main- ernment officials tailor messages to their taining parks and recreation centers and members, particularly when interventions offering the use of their own facilities to are needed to address disparities in obesity other community groups that provide no- and physical activity among racial and eth- or low-cost physical activity programs. nic groups. I Offer Healthy Food at Community Events As part of the Nat ional St rat egy t o Combat O bes it y , community and faith-based organ- L Community and faith-based groups izations should: should provide nutritious food at events to help people foster and maintain I Incorporate Obesity Prevention healthy eating habits. Messages into Events 99 EXAMPLES OF SUCCESSFUL CULTURALLY- APPROPRIATE INTERVENTIONS Community and faith-based organizations income, Spanish-speaking population. are instrumental in implementing successful Incorporating this bilingual aspect into the interventions. Different racial and ethnic program increases the comprehension and groups do not all have the same experiences comfort of participants, thereby improving and priorities, and public health officials must the health of participants. take these divergent backgrounds into account when creating interventions in PATHWAYS - Arizona, New Mexico, order to achieve the health goals. and South Dakota PATHWAYS is a program for students in Project Dulce - San Diego, California grades 3-5 at schools in Native American Project Dulce is a program based in San communities that promotes healthy eating Diego County that provides outreach, edu- and increased physical activity. The PATH- cation, screening, diagnosis, and clinical care WAYS program involves Native American to patients with both type 1 and type 2 dia- leaders in the planning process in order to betes. The program is aimed at low- engage their communities and earn their income, underinsured or uninsured Latino trust, while also developing culturally- adults. Project Dulce works because it tar- acceptable interventions. Classroom materi- gets the barriers that affect this population -- als for the children include stories and activi- specifically the language barrier between ties based on fictional Native American chil- patient and physician. The program involves dren. Although the program did not yield medical assistants who are bilingual, and fea- any statistically significant reductions in stu- tures bilingual health education courses. dents’ percentage of body fat, it did affect Project Dulce also trains community health their knowledge, attitudes, and behavior workers, or promotoras de salud, to raise regarding healthy eating and physical activity. awareness about diabetes among the low- Source: The Partnership to Fight Chronic Disease. 373 E. SCHOOLS “ SCHOOLS CAN PLAY AN IMPORTANT PART IN A NATIONAL EFFORT TO PREVENT CHILDHOOD OBESITY. MORE THAN 95 PERCENT OF AMERICAN YOUTH AGED 5 TO 17 ARE ENROLLED IN SCHOOL, AND NO OTHER INSTITUTION HAS AS MUCH CONTINUOUS AND INTENSIVE CONTACT WITH CHILDREN DURING THEIR FIRST 2 DECADES OF LIFE.374 — MARY STORY, DIRECTOR OF THE ROBERT WOOD JOHNSON FOUNDATION’S HEALTHY EATING RESEARCH PROGRAM. ” Children spend a significant amount of Factors such as large portions, high consumption time in school and consume one-fifth to of soft drinks and high-calorie fast foods, low one-half of their meals there.375 Teachers costs for high-calorie foods and higher costs for and school administrators should use this fruits and vegetables, limited access to healthy time to instill healthy habits in children to foods for the poor, and massive marketing cam- counter the unhealthy messages children paigns targeting children are linked to poor diet, receive outside of school. As researchers high risk for excess weight gain, and in some from Yale University and New York cases diseases such as diabetes.376 University have noted: It is therefore fundamental for schools to The default conditions for children promote incorporate strategies to improve the quali- unhealthy eating and physical inactivity. ty of nutrition and physical activity they pro- 100 vide for students. In order for schools to get required, and limit and/or improve the students to be “as fit as they can be,” they nutritional value of “competitive” foods. must: offer healthy food options, increase As part of the Nat ional St rat egy t o Combat the amount of daily physical activity O bes it y , schools should: School Nutrition Recommendations I Adopt Higher Nutrition Standards Than I Revise Food Contract Policies and USDA Priorities to Focus on Maximum Nutrition L Some states have taken the lead in setting L Contracts for school food suppliers and requirements that are higher than providers should be reviewed to focus on USDA’s minimum requirements for food competing to provide maximum nutri- served in school. Instead of focusing on tion standards to students. delivering minimum nutrition standards, schools and school districts should con- I Evaluate Alternative Fundraising Options centrate on setting high nutrition stan- that Do Not Involve Providing Food of dards for the foods served to students Minimum Nutrition Value to Students that allow them to eat for better health. L Currently many schools, school districts, These standards should be extended to and after-school activities rely on revenue cover “competitive” foods as well as those from vending machines and other food sold during the regular meal program. sales. Jurisdictions should conduct cost-ben- efit analyses of these funds, factoring in the I Ban Sugar Sweetened Drinks impact and cost to children’s health. L Schools should enact the guidelines set Communities must be better informed that forth in the 2007 IOM report “Nutrition while revenue from “competitive foods” may Standards for Foods in Schools: Leading seem like an effective fundraising mecha- the Way toward Healthier Youth” and only nism, it also directly results in a reduction of offer so-called “Tier 1” beverages for sale federal funds to the school lunch program. during school hours. Tier 1 beverages Communities should prioritize finding include water without flavoring, additives other revenue streams to support programs or carbonation; one percent and non-fat or offer more healthful items for sale. milk; and 100 percent fruit juice. High schools may choose to allow the sale of I Provide Professional Development to “Tier 2” beverages which are defined as School Food-Services Staff non-caffeinated, non-fortified beverages L Require those who manage school nutri- with less than 5 calories per portion. tion programs to have appropriate aca- demic preparation and certification; and, I Provide Free Drinking Water ensure that those who manage school L Make sure students have access to free, nutrition programs receive regular pro- clean drinking water in the cafeteria and fessional development on key nutrition gym to encourage water consumption in program topics and strategies. the place of sugary drinks. School Health Screening Recommendations I Evaluate and Refine BMI Initiatives clear and consistent evaluation standards L School BMI screening programs should be to ensure that its intended outcomes and evaluated for effectiveness for reducing any potential unintended consequences and controlling obesity. Schools in which can be measured and monitored. BMI data is collected should establish 101 L BMI measurement programs should be highly qualified staff member, such as coordinated with a safe and supportive the school nurse). school environment for students of all • Establish safeguards to protect student body sizes and a comprehensive set of sci- privacy. ence-based strategies to promote physical • Obtain and use accurate equipment. activity and healthy eating.377 • Accurately calculate and interpret the data. L BMI measurement programs should adhere to safeguards, as detailed by CDC’s Division • Develop efficient data collection of Adolescent and School Health to reduce procedures. the risk of potentially harming students.378 • Avoid using BMI results to evaluate These safeguards include the following: student or teacher performance. • Introduce the program to school staff • Ensure parents receive a clear and respect- and community members and obtain ful explanation of the BMI screening parental consent. results and appropriate follow-up actions. • Train staff in administering the program • Resources are available for safe and (ideally, implementation will be led by a effective follow-up. Physical Activity Recommendations for Schools I Ensure Physical Activity Is a Part of ing with city or county planning and trans- Students’ Daily Lives portation officials, schools can establish L All K-12 students should receive daily safe routes to schools by establishing or physical education. School officials maintaining well-marked crosswalks and should eliminate barriers to physical edu- sidewalks and securing adequate numbers cation, such as the lack of quality teach- of crossing guards around the school. The ers, insufficient time, and lack of profes- need for physical activity should be incor- sional development for P.E. teachers. porated into all planning for building new schools or remodeling existing schools. L Schools should require and P.E. teachers should be trained to not only increase the I Establish Joint Use Agreements with amount of time students spend in physical Community and Faith-Based Organizations education classes but ensure that enough L Schools should encourage activity through- time is actually being spent in moderate-to- out the day and ensure that facilities and vigorous physical activity during P.E. class. space for students provide options for phys- L Schools should provide other physical ical activity before and after school as well activity throughout the school day that as between classes. Joint use agreements reinforces what is taught in physical edu- that include liability protection for both cation, and provide students the oppor- school districts and community and faith- tunity to apply skills and concepts based groups are one way to encourage learned in P.E. Other physical activity these groups to run before- and/or after- opportunities include after-school physi- school programs for children and adoles- cal activity clubs, walk-to-school pro- cents in un-used school space. grams, classroom breaks, and recess. I Improve Nutrition and Health- I Make It Easier for Students to Actively Promotion Education Commute to School L Greater efforts should be made to edu- L Schools and communities should ensure cate students about ways to maintain that their built environments enable stu- good nutrition and exercise regimens dents to walk or bike to school. By work- and how this impacts their health. 102 F. FAMILIES AND INDIVIDUALS “ FAMILIES IN THE UNITED STATES CURRENTLY FACE MANY POTENTIAL OPPORTUNITIES AND CHALLENGES THAT INFLUENCE THE EFFORTS OF HOUSEHOLD MEMBERS TO ENGAGE IN HEALTHY BEHAVIORS. THE CHALLENGES INCLUDE THE STRESSES AND PRESSURES OF DAILY LIVING, ALONG WITH ECONOMIC AND TIME CONSTRAINTS THAT MAKE HEALTHFUL EATING AND DAILY PHYSICAL ACTIVITY DIFFICULT FOR MANY FAMILIES TO ACHIEVE.379 — INSTITUTE OF MEDICINE (IOM) ” Personal responsibility is a major factor in obe- Individuals should also adapt eating patterns sity. Individuals choose between the ham- toward healthier selections and limit their burger and French fries or the turkey burger intake of foods with minimal nutritional and side salad. Parents choose to buy low- value. People should also learn about and sugar cereals instead of the high-sugar options take advantage of resources designed to help advertised on the television. Families decide them stay healthy. If they are unsatisfied with to take a bike ride together instead of sitting at the support they receive, they should make home watching television. Although govern- their opinions known to their local, state, ment is limited in what it can do to model in- and federal government officials. home behaviors, IOM notes that “parents and families can respond to policy changes and ini- I Be Concerned about Obesity and Inactivity tiatives implemented in other settings.”380 For as Health Risks to Their Family Members example, if communities improve bike trails L By encouraging family members to make or add lighting to walking paths, parents and healthy choices, people may help decrease children can engage in more physical activity the number of health problems their loved in a safer environment. In addition, public ones face. Particularly, by helping children education campaigns by federal, state, and stay active and maintain nutritious eating local governments, which are sometimes habits, families may help them avoid poten- undertaken in partnership with private sector tial life-long diseases. Families also have partners, help provide people with informa- leverage as consumers. They should direct- tion to help them with the choices they make. ly communicate with the food, beverage, and marketing industries and use their pur- As part of the Nat ional St rat egy t o Combat chasing power to encourage product devel- O bes it y , families and individuals should: opment and offerings that match the inter- I Factor Health Concerns into Their est they may have for alternative choices. Eating and Exercise Choices I Encourage Mothers to Breastfeed Their L Research has found that even small changes Infants and Toddlers in diet and physical activity can yield big results toward reducing people’s risk for L Research has found that breast-fed infants health problems, ranging from diabetes to gain less weight and stay leaner than their heart disease. Everyone should regularly formula-fed counterparts, as well as show- engage in some form of physical activity. ing lower rates of chronic diseases. 103 G. EMPLOYERS “ WHAT WE DO KNOW NOW IS THAT OBESITY AND OVERWEIGHT ARE CONTRIBUTING ABOUT 27 PERCENT TO THE INCREASE IN PREMIUMS THAT ARE PAID BY PRIVATE EMPLOYERS.381 ” — CHRISTINE FERGUSON, FORMER MASSACHUSETTS HEALTH COMMISSIONER AND DIRECTOR OF THE STOP OBESITY ALLIANCE. The Nat ional St rat egy t o Combat O bes it y should be established for employers to should call for government and private sec- share best practices in worksite wellness tor employers to make certain that every and to foster connections between small- working American has access to a workplace er employers to promote economies of wellness program. scale to offer wellness benefits. Sixty-six percent of the U.S. workforce pop- I Provide Opportunities for Employees to ulation is overweight.382 The economic con- Be Active during the Day sequences of this are reflected in lost work- L For example, businesses should maintain er productivity and higher health insurance clean, well-lit stairwells to encourage employ- premiums. ees to take the stairs. Businesses should also The negative health consequences of inac- focus on providing healthy food options in tivity and poor nutrition are leading to a less vending machines and in cafeterias. productive U.S. workforce and exponential- I Replace Smoke Breaks with Fitness Breaks ly driving up health care costs. It is in the economic interest of every employer and L Employees should be encouraged to the nation as a whole to put a greater engage in physical activity on their lunch emphasis on keeping the workforce healthy hours and breaks. Employers have long and providing preventive care. allowed smokers to step outside for 10 minutes or so throughout the day for a Employers have the ability to influence their cigarette break. Employees should employees through nutrition and fitness pro- instead be offered “walking breaks,” grams, contests, and incentives. A healthy whereby they can leave their desks for 10 workforce equals a more productive work- minutes or so to walk around the office. force, where both employers and employees can benefit from improved health. I Advocate for the Health Insurance Industry to Develop Coding and As part of the Nat ional St rat egy t o Combat Payment Mechanisms for Obesity O bes it y , employers should: Prevention Services I Offer Wellness and Disease Prevention L Generally physicians do not receive enough Programs and Benefits support, resources, or reimbursement from L Offer employees programs and health insurance companies to prescribe preven- benefits that help them stay healthy, tive care for patients with chronic diseases. including nutrition, physical activity, and Employers should work with insurance obesity counseling, subsidizing health companies to ensure that plans cover nutri- club memberships, and providing insur- tion counseling, weight loss and manage- ance discounts for preventive services. ment programs, and similar complementa- Investing in the health of employees not ry services to decrease obesity and prevent only improves productivity but also cuts the development of more chronic diseases. down on absenteeism. A national forum 104 I Provide Opportunities for Female pumping breast milk at a worksite could Employees to Pump Breast Milk potentially facilitate mothers’ continued L A 2007 IOM report on childhood obesity breastfeeding of their infants for the rec- noted that “more widespread availability ommended 4 to 6 months.”383 of convenient and private rooms for EMPLOYMENT AS A BARRIER TO BREASTFEEDING The benefits of breastfeeding for infants and a 2006 study found that working full-time mothers are well documented. According to had a negative effect on breastfeeding dura- the American Academy of Pediatrics a breast- tion.387 While 39 states and D.C. have laws fed infant is 21 percent less likely to die in the that specifically allow women to breastfeed first year than one who is not breast-fed, and in any public or private location, only 19 breast milk helps protect babies against a long states and D.C. have laws related to breast- list of infectious and chronic diseases, includ- feeding in the workplace.388 ing diabetes, obesity and asthma.384 For Mothers who wish to express or ‘pump’ mothers, the benefits include a lower risk of breast milk often lack a clean, private space breast and ovarian cancer as well as protec- where they can do so. According to a tion against weight gain.385 This strong evi- Cochrane Review article on breastfeeding in dence base led the U.S. government to the workplace, “unless these mothers get include breastfeeding goals in the “Healthy support from their employers and fellow People 2010” report. The report set out 2 employees, they might give up breastfeeding main breastfeeding goals: when they return to work. As a result, the I To increase the proportion of mothers duration and exclusivity of breastfeeding to who breastfeed their babies in the imme- the recommended age of the babies would diate postpartum period from 64 percent be affected.”389 The review went on to note to 75 percent. that by promoting and supporting programs to support breastfeeding, not only could I To increase the proportion of mothers employers influence the duration of breast- who breastfeed their babies at 6 months feeding and by doing so improve the health from 29 percent to 50 percent.386 of mother and baby, but the employer However, women returning to work after would also benefit from less work absen- the birth of a child who wish to continue teeism, higher productivity, and increased breastfeeding often face challenges. In fact, employee morale and retention.390 105 H. INSURANCE COMPANIES “ CURRENT GOVERNMENT POLICY PROVIDES DISINCENTIVES FOR INSURERS TO INCORPORATE OBESITY PREVENTION PROGRAMS INTO THEIR POLICIES.391 — ERIC A. FINKELSTEIN, HEALTH ECONOMIST AND CO-AUTHOR OF THE FATTENING OF AMERICA: HOW ” THE ECONOMY MAKES US FAT, IF IT MATTERS, AND WHAT TO DO ABOUT IT. The health care industry also has a role in As part of the Nat ional St rat egy t o Combat the Nat io nal St rat egy t o Co m bat O bes it y . O bes it y , insurance companies should: Insurance companies have to pay out I Promote Prevention Efforts in the excessive amounts of money for obesity- Marketplace related chronic diseases such as hyperten- sion and diabetes. Preventive services may L Offering more prevention-focused benefit cause increased costs for the insurer up options to employers could improve long- front, but reduced rates of obesity will term health and make an economic differ- lower costs over time. ence. This should extend to providing pre- vention support and offering healthy food Health economists, however, have noted and activity capabilities to their own that the current U.S. healthcare system is employees as well. not set up to focus on obesity prevention. According to Eric Finkelstein, co-author of I Work with Companies of All Sizes “The Fattening of America”, private insurers L Insurers should work with small- and medi- reap few benefits from paying for preven- um-sized employers to provide programs tion programs as the majority of the cost-sav- that are affordable. ings are realized when their customers age out of private insurance and are covered I Insurance Companies Should Not under Medicare. He argues that since the Discriminate Based on a Person’s Weight federal government would benefit from any L Obesity or overweight should not be used prevention and wellness programs instituted as a risk factor for determining eligibility by private insurers, the government should for insurance or coverage of treatment. offer financial incentives that make it prof- Insurers should reimburse for all evi- itable for these private companies to pro- dence-based services and treatments. (See vide preventive benefits Section 3: State Responsibilities and Policies for a discussion on state insurance coverage laws.) 106 I. FOOD AND BEVERAGE INDUSTRIES “ THE OVERWHELMING PRESENCE OF FOOD AND BEVERAGE ADVERTISING IN AMERICAN LIFE IS A POWERFUL PART OF THE CONTEXT THAT CANNOT BE IGNORED IN A DISCUSSION OF EATING AND OBESITY TRENDS IN THE UNITED STATES.392 — CONSUMERS UNION, PUBLISHER OF CONSUMER REPORTS ” The Nat ional St rat egy t o Combat O bes it y food, beverage, and candy industry ranked must include the food industry. According sixth in advertising buys in 2004 with a com- to the Center for Science in the Public bined total of $6.84 billion spent on U.S. adver- Interest, there are 3,800 calories available in tising, while the restaurant industry spent a the food supply for each person each day. total of $4.42 billion and ranked 13th in over- The average American, however, needs only all advertising spending.394 2,350 calories per day.393 A separate IOM report on food marketing Not only do we have an overabundance of to children reports that $10 billion a year is food, particularly of foods that are low in nutri- spent to advertise foods, beverages and tional value, but marketing campaigns encour- meals to children and youth, $5 billion of age consumers of all ages with messages to buy which was for TV advertising.395 and eat more. According to Advertising Age, the Total U.S. Advertising Dollars (2004) Food, Beverage, and Candy Companies & Restaurants396 Company Total U.S. Advertising (in millions) Rank McDonald’s $ 1,388.9 18 PepsiCo $ 1,262.2 22 Nestle $ 1,028.3 31 General Mills $ 912.5 35 Yum Brands $ 779.4 46 Mars, Inc. $ 739.8 50 Kellogg Co. $ 647.1 56 Burger King Corp. $ 542.1 67 Coca Cola Co. $ 540.5 68 Sara Lee Corp $ 528.9 71 Wendy’s International $ 435.8 83 Campbell Soup Co. $ 425.3 84 Cadbury Schweppes $ 374.8 91 ConAgra Foods $ 363.8 95 Note: Figures are for 2004 advertising dollars. This includes ‘unmeasured media’ i.e. marketing strategies used by food compa- nies such as direct mail, sales promotion, couponing, catalogs, and special events. As part of the Nat ional St rat egy t o Combat L The food industry should undertake a O bes it y , the food, beverage, and marketing review of the ingredients it uses and, when industries should: possible, reformulate food products. For example, using only whole grains and low- I Develop and Promote Products that ering sodium levels across the board. Encourage Healthful Eating 107 I Inform Customers about Healthy Options I Improve Access to Healthy Foods in All L Providing customers with healthy options Communities and additional product information and L The Grocery Manufacturers Association nutritional values can be good for both (GMA) should encourage members to open health and the bottom line. The food and new supermarkets in underserved communi- beverage industry should provide consis- ties where they can provide these communi- tent nutrition labeling to consumers, based ties with more access to fresh fruits and veg- on product size. Industry should seek the etables and other healthy food options. input of parents and other community Working with local communities, GMA mem- members to establish standards and prac- bers should develop feasibility studies to assess tices for marketing products to children. the economic viability of opening new outlets. SUPERMARKETS EXPERIMENT WITH NUTRITION LABELING The Maine-based supermarket chain, stores that were evaluated failed to receive a Hannaford Bros., developed one of the first single star, some experts wonder if ratings sys- nutritional rating systems for grocery store tems such as Guiding Stars could spur food shoppers in 2006. The system, Guiding Stars, manufacturers to make healthier items. rates meat, dairy, fresh produce, and packaged The ratings system, developed by a team of goods on their nutritional content and awards nutritionists and public-health experts, uses a either a 1-, 2-, or 3-star rating to the prod- formula that credits a food’s score for the uct.397 One-star is “good nutritional value”; 2- presence of vitamins and minerals, fiber and stars are “better nutritional value”; and 3-stars whole grains. It debits the score for trans are “best nutritional value.” Out of a total of fats, saturated fats, cholesterol, added sugars, more than 25,500 rated food items through- and added sodium. The criteria support the out the stores, more than one-quarter (28 recommendations of the 2005 DGAs and are percent) receive one, 2 or 3 stars.398 meant to be used in tandem with the According to store officials, the Guiding Star Nutrition Facts label and the ingredient list. system has had a major impact on shoppers’ Currently, Guiding Stars is used in 164 super- buying habits as consumers flock to products markets across New England and New York. with stars. For instance, sales of cereals, Hannaford Bros.’ parent company, a Belgium- breads, canned and jarred foods, dried pasta, based firm, is introducing the Guiding Stars snack foods, and beverages with one, 2 or 3 system at its Florida chain, Sweetbay, and stars grew steadily at 2-and-a-half-times the plans to expand to Food Lion, a supermarket rate of those without stars.399 Given that over chain present in the southeast and mid- 70 percent of the products sold in Hannaford Atlantic regions of the United States. WARNING LABELS ON VENDING MACHINES -- THE UNIVERSITY OF VIRGINIA EXPERIENCE In May 2004, the University of Virginia from this levy were donated to the universi- Health System placed so-called warning ty’s Children’s Fitness Program. Large signs labels on the 120 vending machines located describing the stop-light system and tax on its premises. The warning labels used were placed next to each vending machine. the stop-light model to distinguish among After one year, red-labeled snack sales the nutritional values of snack foods. A red decreased 5.3 percent, yellow-labeled snack label indicated the item contained 201 calo- sales increased 30.7 percent, and green- ries or more (or 10.1 percent of more satu- labeled snack sales increased 16.5 percent.401 rated fats); a yellow label indicated the item The 5-cent tax raised $6,700. The university contained between 141 and 200 calories (or is now comparing sales of color-coded items 5.1 percent to 10 percent saturated fat); a in one of its hospital cafeterias with the sale green label was placed on items 140 calories of non-color-coded items in a second hospi- or less (and less than 5 percent saturated tal cafeteria to see if the plan merits expan- fat.)400 In addition, the university added a 5- sion to vending machines and cafeteria pro- cent tax to the cost of red items. Proceeds grams in schools throughout the state. 108 J. AGRIBUSINESS AND FARMERS “ WE STRIVE TO FULFILL CONSUMER NEEDS FOR GREAT-TASTING, HIGH-QUALITY FRESH VEGETABLES, AND AFFORDABLE HEALTHY FOOD CHOICES, BUT WE NEED AGRICULTURAL POLICY PRIORITIES TO ASSIST US IN THAT EFFORT.402 ” — MAUREEN TORREY MARSHALL, CO-CHAIR OF THE UNITED FRESH FRUIT & VEGETABLE ASSOCIATION According to USDA, Americans do not eat Institute for Agriculture Trade and Policy, a enough fruit and vegetables. A 2008 study Minnesota-based public policy organization found that based on USDA daily recom- working to ensure fair and sustainable food, mended levels, Americans need to boost farm, and trade systems, “our misguided farm fruit consumption by 132 percent and over- policy is making poor eating habits an eco- all vegetable consumption by 31 percent. nomically sensible choice in the short term.”406 Certain subgroups of vegetables such as As part of the Nat ional St rat egy t o Combat legumes would need to be increased by 431 O bes it y , agribusinesses and farmers should: percent; orange vegetables by 183 percent; and dark green vegetables by 175 percent. I Farmers’ Markets Should Be Equipped Meanwhile, starchy vegetables, such as pota- to Redeem Food Stamps and WIC toes, need to be decreased by 35 percent.403 Coupons. The study notes, however, that the U.S. food L Farmers should work with local and state production system is “currently incapable of governments to equip farmers’ markets providing sufficient levels of fruit and vegeta- with the necessary technology to process bles for all to consume a healthy diet.”404 In electronic food stamp debit cards and fact, 60 percent of all fresh fruits and vegeta- WIC program cards. bles consumed in the U.S. are imported.405 I Work with Schools and Community One reason so much of the fruit and vegeta- Groups to Develop Urban Gardens bles Americans consume is imported is that L Farmers and agribusiness should collabo- the majority of U.S. farm acreage is devoted to rate with schools and community groups growing cash crops such as soy, wheat, corn, to develop urban gardens. Agribusiness and rice. Critics of domestic U.S. farm policy can provide materials while farmers can charge that farm subsidies have led to the provide technical support to urban gar- overproduction of corn and soybeans. These deners. Urban gardens provide access to cheap, surplus crops are used to make high fresh fruits and vegetables to communi- fructose corn syrup and hydrogenated veg- ties who might otherwise not be able to etable oils, which enter the American diet as purchase these healthy foods in their excess sugar and fat. According to the neighborhoods. 109 K. ROLE FOR INCREASED RESEARCH AND EVALUATION “ IF WE WANT MORE EVIDENCE-BASED PRACTICE, WE NEED MORE PRACTICE-BASED EVIDENCE.407 ” — LAWRENCE W. GREEN, FORMER DIRECTOR, OFFICE OF SCIENCE & EXTRAMURAL RESEARCH, PUBLIC HEALTH PRACTICE PROGRAM OFFICE, CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) There is a growing body of research on throughs in developing even more effective nutrition, physical activity, obesity, and obe- obesity prevention and control strategies. sity-related health outcomes and associated 1) Small Changes Make a Big Difference. interventions. Public health officials, how- There is increasing evidence that substan- ever, argue that more effort, money, and tial weight loss is not needed to change evaluation of obesity-prevention programs health outcomes for obese individuals; in are needed in order to develop a set of evi- fact, as little as a 5 to 10 percent weight loss dence-based, proven interventions. There can reduce the risk factors for some dis- is also a need for research “on how to frame eases, including diabetes and some cardio- the obesity issue in order to gain support for vascular diseases. What are the small public health interventions,” according to changes that work? How does a small scientists at Yale University’s Rudd Center change in weight or a small increase in phys- for Food Policy and Obesity. 408 ical activity affect an individual’s health? As part of the Nat ional St rat egy t o Combat 2) Redefine Success. O bes it y , researchers should: Too many Americans, including health I Translate Research into Practice practitioners, have an unrealistic expecta- tion about how much weight loss is L Too often researchers publish the results of enough to achieve meaningful change. their trials or interventions and walk away, The research community should redefine thinking their job is done. For public successful weight loss as it pertains to “con- health practitioners, however, simply hav- trolling or reducing health risks and ing the results of a new study is not enough. costs,” instead of meeting some unrealistic Many of these studies demonstrate the “effi- standard set by society.409 Researchers and cacy” of an intervention or medical treat- clinicians should communicate the impor- ment while failing to consider how “effec- tance of making small changes in order to tive” they will be under real world circum- reduce health risks to the American public stances. Researchers must do a better job of in order to counter the unrealistic views translating their work into practice, which most obese individuals and their health- means considering the full range of envi- care providers hold about weight loss. ronmental and socioeconomic factors that influence people. Researchers must also 3) The Cost of Obesity Prevention. address cost effectiveness and give public What are the costs of various obesity inter- health officials a sense of per capita costs as ventions, particularly those that target they attempt to use these small controlled communities and the environment? interventions on a community-wide level. What are the per person costs associated with obesity interventions? What does it I Challenge to the Research Community: 4 cost to bring an intervention to scale? Key Questions Given the substantial investments in obe- L TFAH has identified 4 key research ques- sity prevention and control, researchers tions that have not yet been adequately should work on developing standardized answered and could help provide break- ways of reporting intervention costs in a 110 manner that is useful for program plan- food accessibility and affordability, and ners and policy makers. racial/ethnic, genetic, and cultural differ- ences. Improved understanding in these 4) The Relationships between Income areas will lead to better intervention and Culture and Obesity. efforts within targeted populations. Researchers should further examine the economics of eating healthy, including L. SPECIAL ISSUES RACIAL AND ETHNIC DISPARITIES IN OBESITY Data from several national surveys of U.S. adult, adolescent and child health, reveal large dis- parities in obesity rates among racial and ethnic minorities.410,411,412 Obesity Rates Among U.S. Adults, High School Students and Children by Racial / Ethnic Group White Black Hispanic Adults413 29.7% 44.9% 36.9%* High School Students414 10.8% 18.3% 16.6% Children415 12.0% 23.5% 18.9% Source: Adult data is from 2003-2004 NHANES; high school data is from 2007 YRBSS; child data is from 2003-2004 NSCH. *Note: Under the Hispanic racial/ethnic group, the adult data is for Mexican-Americans while adolescent and child health data is for all Hispanics. High obesity rates, poor nutrition, and lack The disparities in obesity rates are particularly of physical activity are linked to many dis- worrisome for children given the numerous eases, including diabetes, hypertension, can- long-lasting poor health outcomes associated cer, and heart disease. These diseases are with childhood obesity. If the current trends also found in higher rates among various continue, CDC estimates that one third of all members of racial-ethnic minorities com- children - and one-half of black and Hispanic pared with whites.416 For instance, 22.6 per- children born in 2000 - will develop diabetes.418 cent of American Indians/Alaska Natives age In addition to experiencing higher rates of 20 years and older suffer from diabetes as obesity and overweight than white Americans, do 13.3 percent of African Americans, and African Americans and Hispanics are less likely 9.5 percent of Hispanics, compared to 8.7 to engage in healthy levels of physical activity. percent of whites.417 Physical Inactivity Rates Among U.S. Adults by Sex and Race/Ethnicity419 Male Female White 47.7% 50.4% Black 54.7% 63.9% Hispanic 58.1% 59.5% Source: 2005 BRFSS data. Note: Physical inactivity is defined as adults who did not engage in at least 30 minutes a day of moderate- intensity activity on 5 or more days a week, or at least 20 minutes a day of vigorous-intensity activity on 3 or more days a week. 111 Percentage of U.S. High School Students and Children Not Participating in Recommended Levels of Physical Activity by Racial / Ethnic Group White Black Hispanic High School Students 22.4% 32.0% 27.1% Children 26.5% 30.9% 37.1% Source: High school student data is from 2007 YRBSS; Child data is from 2003-2004 NSCH. For high school students, it is the percent that did not participate in 60 or more minutes of physical activity on any day.420 For children, it is the percent that did not participate in physical activity that lasts at least 20 minutes and causes sweating and hard breathing on 3 or more days per week.421 Researchers cite a number of factors behind Islanders.430 African Americans, Hispanics and the disparities in obesity rates and physical American Indians/Alaska Natives are also inactivity levels. These include the following: more likely to be uninsured than are whites. Thirty-four percent of Hispanics, 32 percent I Cultural perceptions of food, eating, phys- of American Indians/Alaska Natives, and 21 ical activity and weight in racial and ethnic percent of African Americans are uninsured communities.422 compared to 13 percent of whites.431 I Physical environments that do not sup- Lack of health insurance translates into less port physical activity, for instance the lack access to health care providers and less chance of parks and recreation centers.423 of receiving a diagnosis of obesity. According I Fast-food restaurants and convenience to a 2006 study, whites are 3 times more likely stores are much more accessible in low- to receive a diagnosis of obesity than blacks.432 income neighborhoods than chain super- Given that research suggests that individuals markets that offer a healthier array of foods who receive a diagnosis of overweight or obe- including fresh fruits and vegetables.424 sity from their health care providers are more likely to lose weight than those who do not I Crime rates and perceptions of danger receive a diagnosis, health care providers in are higher in low-income neighbor- minority-communities should be trained and hoods.425 Whether real or perceived, hav- encouraged to speak with their patients about ing unsafe neighborhoods means a the health risks associated with obesity, poor decrease in children walking to school and nutrition and sedentary lifestyle.433 Expanding playing outside and an increase of time minorities’ access to health care and insurance spent in front of the television.426 should also be top priorities. I Low-income minority families may have little In addition to addressing access to health care, money left over to buy food, specifically healthy behavior change campaigns to modify eating food, which is generally more expensive.427 habits and promote increased physical activity I Longer working hours and commuting are needed to address some of the cultural times among low-income parents may issues behind the disparities in obesity. interfere with time spent buying and According to the National Institute of preparing food, and transporting children Environmental Health Sciences, government to after-school recreation activities.428 should also focus on changes to the built envi- ronment.434 (See Section 5: National Strategy to I Use of food as a means to deal with stress Combat Obesity for recommendations on the related to poverty, racial discrimination, built environment.) violence and abuse.429 Finally, more research, both into the factors I Lack of health insurance limits minorities’ behind and the interventions needed to access to health care providers. address disparities in obesity, nutrition, and According to the Henry J. Kaiser Family physical activity are needed. A major chal- Foundation, racial and ethnic minorities are lenge for academic researchers is likely to be more likely to be poor than are whites. Over minority communities’ distrust of medical half of Hispanics, African Americans, and research.435 However, by engaging commu- American Indians/Alaska Natives are poor or nity members in the research process scien- near poor, compared with 26 percent of tists can ensure that the evidence-base whites and 33 percent of Asians and Pacific behind obesity disparities is expanded. 112 CHILDHOOD OBESITY IN RURAL AMERICA Many Americans may associate living in a compared to 18 percent of urban children.440 rural setting with a healthy lifestyle because it According to Save the Children, the leading may offer opportunities for physical activity, independent organization promoting chil- consuming locally grown produce, access to dren’s health and well-being, “children who open land and clean air that invite outdoor live in poverty have a greater challenge activities.436 But recent studies have found engaging healthy lifestyle behaviors to sup- that rural children are just as likely to be port normal growth and development.”441 obese as urban children.437,438,439 An analysis One challenge is lack of access to healthy from the South Carolina Rural Health foods, beverages, and meals. A 2007 study Research Center, using the 2003 National found more than 800 counties where rural Survey on Children’s Health data, found that: residents live 10 miles from a large food retailer.442 Another challenge is lack of access I 31.5 percent of rural children aged 10 to 17 to opportunities and facilities for regular years old were overweight or obese, com- physical activity.443 Poverty and food insecuri- pared to 30.4 percent of urban children. ty are only 2 factors behind the high rates of I 16.5 percent of rural children were obese, childhood obesity in rural areas. In addition, compared to 14.4 percent of urban children. children living in rural areas struggle with a lack of resources and infrastructure to sup- I Rural African-American children had the port physical activity and healthy eating.444 highest levels of overweight (44.1 percent) and obesity (26.3 percent) compared to all In order to address the problem of rural other racial and ethnic groups. childhood obesity, in 2005 Save the Children launched the CHANGE (Creating Healthy, I Children living in the South were most Active, and Nurturing Growing-up likely to be overweight or obese (33.1 Environments) Program to increase rural chil- percent), followed by the Midwest (30.2 dren’s access to daily physical activity and a percent), the Northeast (29.5 percent), healthy snack. The CHANGE Program oper- and the West (28.1 percent). ates in 5 rural regions of the U.S. where I As family income increased, the proportion poverty rates are highest: Appalachia, the of children who are overweight decreased Southeast, the Mississippi River Delta, significantly among rural and urban residents. California’s Central and San Bernardino Valley, and Native American reservations in I 25.4 percent of rural children failed to the Southwest. During the 2007-2008 school meet physical activity recommendations. year, the CHANGE program served nearly I 40.7 percent of rural children did not par- 7,000 children at 95 sites in 12 states. A ticipate in any after school sports teams large-scale community-based intervention is or activities. underway called the CHANGE Study, which is adapting and testing Tufts University’s I Nearly half of rural children (48 percent) Shape Up Somerville model. The research spent at least 2 hours a day with electron- will identify a package of interventions to ic entertainment media (TV viewing, reduce rural children’s obesity risk and create video games, computer use). environments that support healthy lifestyle Poverty rates are also quite high for rural behaviors. Results are expected in 2010. children, 21 percent of whom live in poverty 113 BABY BOOMERS AND OBESITY In 1946, 3.4 million babies were born -- a jump of 22 percent I Sixty-two percent of 50-64 year-olds claim to have at least from the previous year, a trend that continued until 1964, cre- one of the following obesity-related chronic conditions: ating a population bulge we call “baby boomers.”445 With the diabetes, heart disease, hypertension, cancer, arthritis, and first round of baby boomers turning 60, there are questions high cholesterol. about the overall health of the generation: Are they living longer and healthier lives? Is the health care system prepared I The highest prevalence of obesity occurs among women in to handle the boomer demographic bulge? Currently, scien- their 50’s -- fitting squarely into the baby boomer population.450 tists know the following about the baby boomers: I Individuals obese in middle-age are projected to be twice as I Access to better food and health care has improved, but con- expensive to cover under Medicare as healthy weight people.451 sumption of high fat foods and rates of obesity has increased, I Data from a 2007 U.S. Health and Retirement Study shows while rates of physical activity remain unchanged.446 people in their early to mid-50s reporting more health prob- I The number of obese Americans 55-64 has increased from lems and a lower quality of life than previously described.452 31 percent (1988-1994) to 39 percent (1999-2002).447 While many studies point to startling statistics relating to I A study published in 2005 found that members of the baby increasing rates of obesity among the baby boomer popula- boom generation have a higher prevalence of obesity, and tion, other analysts are finding contradictory health trends became obese at younger ages, than their predecessors in among the boomer generation. For example, descriptions the silent generation.448 about health in the National Health Interview Survey show a higher percentage of those 50-64 reporting health as “very I A report from the Centers for Medicare and Medicaid good” or “excellent” in 2004 than in 1994.453 Although there Services predicts that unless major health changes occur, is conflicting data, there is no argument that very soon U.S. health care spending will reach $4.3 trillion (almost 20 Medicare will be inundated with a population bulge of percent of the gross domestic product) by 2017 as the first boomers, many of whom are overweight or obese. of the baby boomers begin to enroll in Medicare.449 MENTAL HEALTH, STRESS AND OBESITY There is growing evidence documenting the association between The significant associations between obesity and poor mental obesity and poor mental health. Researchers in the Adult and health has led CDC researchers to “suggest that public health inter- Community Health division of CDC analyzed 2006 BRFSS data ventions should address mental and physical health as a combined and found that depression and anxiety are associated with entity and that programs to simultaneously improve people's men- obesity.454 Adults currently or previously diagnosed with depres- tal and physical health should be developed and implemented.”459 sion were 60 percent more likely to be obese, and those with Stress and Obesity anxiety disorders were 30 percent more likely to be obese than A 2007 study found a direct connection between stress and obesi- their non-depressed counterparts.455 Adults with depression or ty. Scientists, performing studies on mice, found a chain of molecu- anxiety were also less likely to engage in regular physical activity.456 lar events that link chronic stress with obesity. The study found A separate study analyzing data from more than 41,000 that when stressed and non-stressed mice were fed the same, Americans who participated in the National Epidemiologic high-calorie diet, the stressed mice gained twice as much fat.460 Survey on Alcohol and Related Conditions found that adults with According to the study, the long-term combination of stress and a high BMI (BMI ≥ 30) were more likely to suffer from mood, anx- high fat/high sugar diet will lead to obesity and metabolic syn- iety, and personality disorders than people of normal weight drome symptoms such as hypertension and glucose intolerance.461 (18.5 ≤ BMI < 25) .457 Even individuals in the moderately over- In addition to the traditional methods of weight loss, researchers weight category (25 ≤ BMI < 30) were at an elevated risk of suggested also including stress reduction therapy and a neuropep- anxiety disorders compared to those of normal weight.458 tide Y receptor inhibitor to induce fat “melting.”462 BINGE EATING DISORDER AND OBESITY Binge eating disorder is a classified psychiatric disorder which prevalence, 25 percent or more, has been reported by affects more than 7 million adults in the U.S.463 Binge eating patients who are obese or seeking help for weight loss.465 is a compulsive pattern of regular bingeing of unusually large Because long-term weight management is more likely in an amounts of food and complete loss of control over one's eat- individual who is able to control eating patterns, physicians ing patterns.464 While only 1 to 3 percent of the general pop- treating obese patients need to address the behavioral and ulation is affected by binge eating disorder, a much higher psychological components of binge eating disorders.466 114 WHAT ARE OTHER COUNTRIES DOING? According to the World Health Organization (WHO), globally menting new rules that limit exposure to fatty, sugary, food ads there are some 1.6 billion adults (age 15 and older) who are on children’s television.474 overweight and 400 million adults who suffer from obesity; at According to Will Cavendish, Director of Health and Well-Being, least 20 million children under the age of 5 years were over- United Kingdom Department of Health, there were 2 major fac- weight globally in 2005.467 WHO projects by 2015 that tors that led the British government to draft and adopt the com- approximately 2.3 billion adults will be overweight and more prehensive obesity-prevention plan. First, in October 2007 the than 700 million will be obese.468 British government forecasting office published a report that The problem is not confined to the industrialized countries; in looked at obesity trends in the United Kingdom and the associat- fact, overweight and obesity are on the rise in less developed ed economic costs. The report estimated that by 2050 at least countries, particularly in urban settings. 50 percent of adults and 25 percent of children under age 16 would be obese, which would cost society and business an esti- In response to the global obesity problem, in May 2004 WHO mated 49.9 billion pounds a year (or some $100 billion) if the adopted the Global Strategy on Diet, Physical Activity and epidemic were not brought under control through dramatic Health.469 The Global Strategy has 4 main objectives: changes across British society.475 The report’s authors compared 1. Reduce risk factors for chronic diseases that stem from the problem to global climate change and noted that it would unhealthy diets and physical inactivity through public health require a government-wide, multi-sectoral approach to solving actions. the problem. “This really changed the environment in the U.K. 2. Increase awareness and understanding of the influences of from one where obesity was a passing interest to one in which diet and physical activity on health and the positive impact obesity is a serious concern,” Cavendish said at an April 2008 of preventive interventions. obesity conference in Washington, D.C.476 3. Develop, strengthen and implement global, regional, national The second was a national listening tour the newly elected policies and action plans to improve diets and increase prime minister, Gordon Brown, carried out soon after assuming physical activity that are sustainable, comprehensive and office in 2007. The tour was to focus on health issues and what actively engage all sectors. stood out, according to Cavendish, was that parents’ number 4. Monitor science and promote research on diet and one concern was childhood obesity. These 2 factors -- a strong, physical activity. evidence-based call to action and the political leadership and buy-in -- were enough to get all levels of government working Although the United States has failed to develop a national together, according to Cavendish. The national government plan, WHO reports that there are 36 countries that have also put resources behind the national plan: 372 million pounds, adopted national plans regarding diet and physical activity.470 A or $726 million over the next 3 years.477 searchable database of countries with national plans is available online at http://www.who.int/infobase/dpas/dpas.aspx. France The French government released a national childhood obesity United Kingdom plan in January 2004 that focuses both on primary prevention -- The British released a cross-sectoral, multi-agency obesity pre- with recommendations for families, teachers, and communities, vention plan in January 2008, “Healthy Weight, Healthy Lives: A and secondary prevention -- with recommendations for health Cross-Government Strategy for England”, and set out an ambi- professionals. tious goal to be the first major nation to reverse the trend of increasing obesity and overweight among the population.471 The The French plan also focuses on the importance of social and plan’s initial focus is on children and by 2020 the goal is to reduce physical changes to the environment. According to Michel the proportion of overweight and obese children to 2000 levels. Chauliac, Coordinator, National Nutrition and Health Program, French Ministry of Health, the overall goal is to improve health, One of the critical components of the U.K.’s anti-obesity strate- with nutrition and physical activity seen as critical components of gy is the national commitment to changing the physical and health. He says the French government wants consumers to make social environments in communities. The government is informed choices but realizes that choice is limited by the environ- redesigning several communities into so-called “healthy towns” ment. “So the goal is to improve the nutritional environment.”478 that feature bike lanes and facilities to encourage people to commute by bike and foot instead of car. A pilot project in the To improve the nutritional environment, France has: town of Peterborough led to a 13 percent reduction in car use I Banned vending machines in all schools; and a 21 percent increase in walking.472 I Mandated nutritional qualities of school meals; The strategy also includes public service announcements to edu- I Incorporated health messages on all manufactured foods cate parents about healthy eating habits and activity levels for and beverages; and children. Already, Britain has implemented tough new food-stan- I Considered a possible ban on TV advertisements for children. dards for school lunches and other school foods, in addition to requiring schoolchildren to engage in at least 2 hours of physical The plan is already showing promising results according to education and activity a week.473 The government has also French researchers who reported the findings from 2 different cracked down on food manufacturers and marketers, imple- studies that showed a leveling off of childhood obesity rates.479 115 A APPENDIX Methodology for Obesity and Other Rates Using BRFSS Data for this analysis was obtained from the able (PSU). Omission of the stratification Behavioral Risk Factor Surveillance System variable in STATA implies no stratification of (BRFSS) dataset (publicly available on the PSUs prior to first-stage sampling. Omission web at www.cdc.gov/brfss). The analysis was of the primary sampling unit variable conducted by Daniel Eisenberg, PhD, and implies one-stage sampling of elements and Edward N. Okeke, MBBS, of the Department no clustering of sampled elements. of Health Management and Policy of the Omission of the sample weight implies University of Michigan School of Public equally weighted sample elements. Mean Health. proportions for each variable were estimated using the svy: proportion command. BRFSS is an annual cross-sectional survey designed to measure behavioral risk factors Variables of interest included BMI, physical in the adult population (18 years of age or inactivity, asthma, smoking, high blood pres- older) living in households. Data are collect- sure and diabetes. BMI was calculated by ed from a random sample of adults (one per dividing self-reported weight in kilograms by household) through a system of telephone the square of self-reported height in metres. surveys. The BRFSS currently includes data Obesity was then defined as calculated BMI from 50 states, the District of Columbia, greater than or equal to 30 and overweight Puerto Rico, Guam, and the Virgin Islands. was defined as calculated BMI greater than The most recent data available was 2007. or equal to 25 but less than 30. For the phys- ical inactivity variable a binary indicator To account for the complex nature of the equal to one was created for adults who survey design and obtain estimates accu- reported not engaging in physical activity or rately representative at the state level, exercise during the previous thirty days researchers used sample weights provided other than their regular job. For diabetes, by the CDC in the dataset. The main pur- researchers created a binary variable equal pose of weighting is to reduce bias in popu- to one if the respondent reported ever being lation estimates by up-weighting population told by a doctor that he/she had diabetes sub-groups that are under represented and and for smoking we created a variable equal down-weighting those that are over repre- to 1 if the respondent self-identified as a cur- sented in the sample. Also, estimation of rent smoker. For asthma, all respondents variance (which indicates precision and is who reported ever being told that they had used in calculating confidence intervals), asthma were coded as 1 and 0 otherwise. needs to take into account the fact that the elements in the sample will generally not be The hypertension variable481 had to be treat- statistically independent as a result of the ed differently because of changes in how the multistage sampling design. question was asked. Prior to 2003 the ques- tion asked was “Have you ever been told by We specified the sampling plan to STATA480 a doctor, nurse or other health professional using the svyset command and the following that you have high blood pressure?” set of weights: sample weight variable Respondents could answer “yes”, “no”, or (FINALWT), first-stage stratification variable “don’t know/not sure”, or could refuse to (STSTR), and primary sampling unit vari- 116 answer. In 2003 the question was modified another category was created: for border- so that respondents who said “yes” were line or pre-hypertensive respondents, bring- asked a follow-up question: “Was this only ing the total number of categories to 6 when you were pregnant?” Respondents (from 4 in 2001). See Figure 1 below for a answering “yes” to the follow-up question summary of the changes. were coded separately. Starting in 2005, yet Figure 1: Summary of Changes in Hypertension Variable 2001 2003 2005 Yes Yes Yes No No No - Yes (but female told only Yes (but female told only during pregnancy) during pregnancy) - Borderline/Pre-hypertensive Don’t know/Not sure Don’t know/Not sure Don’t know/Not sure Refused Refused Refused In order to be able to compare across dif- across years in which the question format ferent years, researchers made several stayed the same. TFAH used the more con- assumptions: servative estimates in the report. 1. Researchers assumed that respondents For all variables researchers calculated falling in the “yes (but female told only dur- rolling 3 year averages, first by averaging ing pregnancy)” category would have been data from 2004-2006 and then by averaging classified as a “yes” in 2001. This is plausible data from 2005-2007 (after merging data given that the only difference between from the relevant time period).483 2001 and later years is that if the respon- Researchers reported mean proportions for dent answered “yes” to the main question, each 3-year period as well as standard errors the follow-up question was not asked. and 95% confidence intervals for all vari- ables of interest. In addition they carried 2. For respondents classified as “border- out a Pearson statistical test of proportions line/pre-hypertensive”, researchers made 2 and reported which states experienced a sig- assumptions: first they assumed that in pre- nificant increase or decrease (significant at vious years respondents would have been the .05 level) between time periods. coded as a “yes” and then they assumed that respondents would have been coded The various sample sizes are included in the as a “no”. Researchers ran calculations spreadsheet. Note: Guam is excluded from under both assumptions and the qualitative the analysis and this is reflected in the sam- conclusions were similar.482 For comparison ple size. We also excluded all observations we also present results calculated only with missing values from the analysis.484 117 B APPENDIX Methodology for State Obesity Plan Review TFAH researchers searched the public health department and governor’s website of each Researchers read and evaluated each state plan based on the following criteria: state and D.C. for physical activity, nutrition, Does the state obesity plan involve multiple and obesity plans. The search took place in state agencies? April 2008. Several states, including Idaho, Indiana, Kansas, Tennessee, and D.C., had an Does the plan specifically assign roles & overall health promotion plan which includ- responsibilities to state agencies? ed a section on obesity, but these were not Does the plan contain clear and measura- counted as strategic plans to combat obesity. ble objectives? Virginia and D.C. had state plans aimed at the prevention of obesity only among chil- Are the plan’s objectives related to reducing dren, which TFAH counted as strategic plans rates of obesity? to combat obesity. Does the plan link funding to objectives? If a plan was not available online, TFAH Does the plan include private sector (busi- researchers emailed the most appropriate ness, industry) and community groups? person or department in that state to inquire whether or not the state had a strategic plan Does the plan include provisions regarding to prevent and treat obesity. States that did a healthier state workforce? not respond to inquiries via email were con- Does the plan have a system for evaluation tacted via the National Association of and review? Chronic Disease Directors. In this way, TFAH was able to confirm the status of each state’s obesity plan. 118 Overview of Federal Programs That Impact Obesity C APPENDIX The following chart contains an overview of the cabinet-level agencies and the federal programs within which impact obesity: U.S. Department of USDA is responsible for a range of food and nutrition programs that impact obesity, including: Agriculture (USDA) I Nutritional advice and guidance. I Nutrition assistance programs. I Food and obesity education campaigns. I Distribution of food products to schools. I Oversight and protection of the nation’s agricultural and dairy markets. AGENCY PROGRAM/ INITIATIVES Food and Nutrition USDA’s Division of Food, Nutrition, and Consumer Services (FNCS) is central to obesity Services (FNS) policies. FNCS is one of 7 agencies in USDA, and it includes 2 departments relating to obesity: Food and Nutrition Services (FNS) and the Center for Nutrition Policy and Promotion (CNPP). FNS administers nutrition assistance programs to needy and eligible populations through a variety of food assistance programs and comprehensive nutrition education efforts.485 Food and Nutrition The Food Stamp Program served approximately 26.5 million people in FY 2007 at a cost of Services (FNS) $34.8 billion. Food and Nutrition The National School Lunch Program is a federally assisted meal program that serves free or Services (FNS) low-cost lunches to low-income children throughout the nation. It serves lunch to over 30.1 million children each day in over 101,000 public and nonprofit private schools and residential child care institutions.486 There are nutritional requirements -- such as offering milk with different fat contents -- that are aligned with the U.S. Dietary Guidelines, and these will be updated to reflect recent changes to the Guidelines. Schools are reimbursed between $2.07 and $2.47 for reduced price and free lunches, respectively.487 In FY 2006, the federal government spent $8.2 billion on the lunch program.488 A similar program serves subsidized school breakfasts. Food and Nutrition The Fresh Fruit & Vegetable Program (FFVP) provides fresh and dried fruits and fresh Services (FNS) vegetables throughout the school day. Participating schools are required to publicize the availability of the fresh fruit, dried fruits and fresh vegetables to the student body. One of the program’s goals is to teach students about the importance of good nutrition, including eating fresh fruit and vegetables. The reauthorized Farm Bill provides for a nationwide expansion of the Fresh Fruit and Vegetable Program, and requires state agencies to reach out to schools with significant numbers of children eligible for free or reduced price meals to inform them of their eligibility for the program. The bill also authorizes mandatory funding of $40 million for the program in 2008; $65 million in 2009; $101 million in 2010; $150 million in 2011, and $150 million indexed for inflation in 2012. Food and Nutrition The Child and Adult Care Food Program (CACFP) provides meals and snacks to 2.9 million Services (FNS) low-income children in day care and 86,000 adults who receive care in nonresidential adult day care centers.489 Reimbursement for meals is based upon income. Food and Nutrition The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Services (FNS) is a federal grant program that provides supplemental food, counseling, and nutritional education for low-income pregnant or postpartum women and children up to age 5.490 Fifty-four percent of all U.S. infants received WIC benefits in 2000, as did 25 percent of U.S. children ages 1-4.491 WIC food pack- ages also provide supplements for the children’s mothers. In FY 2007, the federal government spent $5.5 billion on WIC and served about 8.2 million Americans, who on average received about $39 a month for food purchases.492 119 AGENCY PROGRAM/ INITIATIVES Food and Nutrition The WIC Farmers’ Market Nutrition Program (FMNP) provides fresh, unprepared, locally Services (FNS) grown fruits and vegetables to WIC participants. Established by Congress in 1992, the program served 2.5 million WIC participants in FY 2006 who were able to buy fresh produce from the 14,259 farmers, 2,896 farmers’ markets and 2,136 roadside stands that were authorized to accept FMNP coupons.493 The program generated over $22.4 million in revenues for participating farmers in FY 2006.494 Food and Nutrition The Seniors Farmers’ Market Nutrition Program (SFMNP) is another means by which USDA Services (FNS) provides low-income citizens, in this case senior citizens, with coupons to buy fresh produce at local participating farmers’ markets.495 In FY 2007, 46 states and federally recognized tribal agencies received grants to operate the SFMNP program. The program received $16 million in FY 2007 and served over 800,000 needy seniors.496 The new Farm Bill provides $20.6 million in mandatory funding each year for the program over the next 5 years. Food and Nutrition The Commodity Supplemental Food Program (CSFP) targets low-income pregnant and Services (FNS) breastfeeding women, other new mothers up to one year postpartum, infants, children up to age 6, and elderly people at least 60 years of age by supplementing their diets with USDA commodity foods. The population served is very similar to the WIC program, but CSFP also serves low-income senior citizens and provides food instead of the food vouchers WIC participants receive.497 In FY 2007, an average of more than 466,000 people participated in CSFP each month, including just under 433,000 elderly people and more than 33,000 women, infants, and children.498 For FY 2008, Congress appropriated $139.7 million for CSFP499 The President’s budget would zero out the . program in FY 2009. Food and Nutrition The Center for Nutrition Policy and Promotion (CNPP) develops nutritional education Services (FNS) information and works to disseminate research findings through outreach materials to targeted populations.500 Dietary guidelines and the Food Pyramid are CNPP’s notable initiatives; both were updated in 2005. U.S. Department of The Department of Defense is responsible for national security. Defense (DOD) AGENCY PROGRAM/INITIATIVES To combat the growing obesity problem among U.S. servicemen and women, each of the armed services has developed programs to promote fitness and health: the Army has Weigh to Stay; the Navy and Marine Corps have ShipShape; the Air Force has Fit to Fight. These programs use nutrition and fitness counseling to move military personnel and their families toward healthier food choices, exercise habits, and lifestyles. Military Health System The U.S. military healthcare system, TRICARE, has a healthy choices initiative called HEALTH (Healthy Eating and Active Living in TRICARE Households) that helps participants reach their desired weight and teaches them how to live a healthier lifestyle. TRICARE members who join HEALTH receive information on healthy meal planning, create a personalized exercise program, and work with a phone counselor and primary care manager to determine individual weight loss goals and how to maintain a healthy weight.501 Department of Defense The Department of Defense Education Activity (DoDEA) manages the education programs Education Activity for children of U.S. military personnel and civilian personnel who are stationed at bases at home (DoDEA) and abroad. The 199-school system employees some 8,700 teachers and reaches 88,000 students. The system is set up to handle the needs of these children who change schools frequently due to their parents’ assignments. To maintain continuity, the school system teaches from a uniform curriculum and standards. Included in the DoDEA curriculum are lessons on physical activity, nutrition and physical education.502 120 U.S. Department The Department of Education runs federal education programs and implements and collects data of Education on federal education policies such as No Child Left Behind. The high profile nature of the Department gives the secretary of education the ability to draw national attention to key issues, for instance, childhood obesity and physical inactivity. AGENCY PROGRAM/INITIATIVES Office of Safe and Carol M. White Physical Education Program provides competitive grants to schools and Drug-Free Schools community-based organizations to implement and expand quality PE programs for students in (OSDFS) kindergarten through grade 12. The President’s budget proposes to zero out this program, which was funded at $75.6 million in FY 2008. U.S. Environmental The EPA’s mission is to protect human health and the environment. Protection Agency (EPA) AGENCY PROGRAM/INITIATIVES The EPA Smart Growth Program helps state and local governments develop communities that are environmentally friendly, preserve open space and historic buildings, and encourage the use of public transportation or active commuting (biking or walking) by putting amenities such as restaurants and businesses near homes. The Smart Growth Program also works on the clean-up of contaminated properties, so-called Brownfields, to ensure that the local residents are part of the economic redevelopment process for these sites. The president’s FY 2009 budget proposes $1.191 billion for Healthy Communities and Ecosystems, of which the Smart Growth Program is a small component. That is $36.4 million less than the FY 2008 enacted budget. U.S. Federal Trade The FTC deals with both consumer protection and fair business competition. Commission (FTC) AGENCY PROGRAM/INITIATIVES In May 2006, FTC and HHS released a report “Perspectives on Marketing, Self-Regulation, & Childhood Obesity: A Report on a Joint Workshop of the Federal Trade Commission” recommending concrete steps that industry can take to change their marketing and other practices to make progress against childhood obesity. While the report was an important step forward, all the recommendations detailed in the report are voluntary. How many of them will actually be implemented by the food, media and entertainment industries remains to be seen. FTC and HHS have said they will closely monitor industry progress in implementing the recommendations set forth in the report, and issue a follow-up report assessing the progress that industry has made.503 121 U.S. Department of As the nation’s principal agency for protecting the health of all Americans and providing essential Health and Human human services, HHS has a key role to play in the national effort to combat obesity. Services (HHS) AGENCY INITIATIVES/PROGRAMS Administration on AOA launched You Can! Steps to Healthier Aging in September 2004. The goal of the Aging (AOA) program was to promote physical activity and sound nutrition in elderly populations. By September 30, 2006 when the campaign ended, a total of more than 2,800 organizations had made a commit- ment to reach 4.2 million older adults with information and 436,000 with programs.504 Centers for Disease The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) Control and Prevention at the CDC has been leading the agency’s obesity-related initiatives. CDC manages a wide range of programs aimed at combating obesity including state, community, school, and employer-based initiatives, as well as marketing campaigns. A number of CDC’s key programs are discussed below. Four of CDC’s major obesity-related initiatives are grant-based programs -- Preventive Health and Health Services Block Grant, Division of Adolescent and School Health (DASH), Division of Nutrition, Physical Activity and Obesity (DNPAO), and Division of Adult and Community Health (DACH). Centers for Disease The Preventive Health and Health Services Block Grant (PHHSBG) awarded grants to Control and Prevention all 50 states and the District of Columbia in FY 2007. The grants are used “to fill funding gaps in programs that deal with leading causes of death and disability,” as well as to enable states to respond rapidly to public health emergencies, such as a foodborne disease outbreak.505 President Bush’s FY 2009 budget proposal recommended zeroing out the PHHSBG, which was funded at $97,270,000 in FY 2008. Centers for Disease The Division of Nutrition, Physical Activity, and Obesity (DNPAO) funds programs that use Control and Prevention various nutrition and physical activity intervention strategies to address obesity and other chronic diseases. Under the new 5-year grant cycle that began in June 2008, 23 states received funding, 5 fewer than the previous grant cycle. President Bush’s FY 2009 budget proposal recommended funding DNPAO at $42,018,000, just slightly below the FY 2008 amount of $ 42,191,000. Centers for Disease The Division of Adolescent and School Health (DASH) seeks to prevent health adverse Control and Prevention behavior in school-aged children and young adults. DASH’s Coordinated School Health Program provides funding for 22 states and one tribe to develop coordinated school health programs. The President’s FY 2009 budget proposal recommended $13,553,000 for DASH’s Coordinated School Health Program, which deals specifically with nutrition, physical activity, and tobacco slightly below the FY 2008 level of $13,609,000. Centers for Disease The Division of Adult and Community Health (DACH) is charged with providing crosscutting Control and Prevention chronic disease and health promotion expertise and support to CDC’s National Center for Chronic Disease Prevention and Health Promotion. It oversees 2 crucial programs in the fight to prevent and treat obesity: the Steps Program and the Pioneering Healthier Communities Program. The Steps Program funds communities across the country to show how local initiatives can reduce the burden of chronic diseases such as obesity, diabetes, and asthma by encouraging people to be more physically active, eat a healthy diet, and not use tobacco.506 The President’s FY 2009 budget proposes a $9,617,000 cut to the Steps Program, which was funded at $25,158,000 in FY 2008 and $42,904,000 in FY 2007. The Pioneering Healthier Communities program, a partnership with the CDC and the YMCA of the USA, addresses physical inactivity, poor nutrition, obesity and related chronic diseases in communities across our nation. Pioneering Healthier Communities impacts 20 new communities each year; over 60 communities have been reached since FY 2005. The President’s FY 2009 budget proposal zeroes out the program, a decrease of $2.9 million from FY 2008. Centers for Disease The National Center for Health Statistics (NCHS) is the nation’s health statistics agency. Control and Prevention NCHS data is used to inform public health and health policy.507 NCHS uses a variety of approaches to collect data including birth and death records, medical records, interview surveys, and direct physical exams and laboratory testing. As the Institute of Medicine has noted, “surveillance is essential to maximize the probability of success and efficiency of effort,” in the fight against obesity.508 As such NCHS should be a key component of the federal government’s National Strategy to Combat Obesity. The President’s FY 2009 budget proposes $124,701,000 for health statistics, an increase of $11,065,000 over the FY 2008 level of $113,636, 000. 122 AGENCY INITIATIVES/PROGRAMS Centers for Disease The Behavioral Risk Factor Surveillance System (BRFSS) is the only consistent source of state Control and Prevention and community level data on overweight and obesity available to state and local health departments. In addition to overweight and obesity data, BRFSS enables the analysis of related health risks, such as diabetes, physical inactivity, and hypertension, as demonstrated by this report. The Presidents FY 2009 budget proposes $7,269,000 for the BRFSS, a decrease from $7,299,000 from FY 2008. Centers for Disease The Healthier Worksite Initiative is a website CDC developed for its own employees “with Control and Prevention the vision of making CDC a work site where ‘healthy choices are easy choices,’ and sharing the ‘lessons learned’ with other federal agencies.”509 Resources including program design tools and information, policies, and toolkits are available online at http://www.cdc.gov/hwi. Centers for Medicare and Medicare and Medicaid pay over half of the nation’s bill to treat obesity-related conditions -- $39 billion Medicaid Services (CMS) out of a total of $75 billion in direct medical costs each year. CMS, through its decisions regarding coverage of obesity prevention and treatment services, can dramatically affect the course of the obesity epidemic. Food and Drug In March 2004, the Food and Drug Administration released the Calories Count report, the result Administration (FDA) of an interagency working group on obesity.510 The report includes recommendations to strengthen food labeling, to educate consumers about maintaining a healthy diet and weight and to encourage restaurants to provide calorie and nutrition information. It also recommends increasing enforcement to ensure food labels accurately portray serving size, revising and reissuing guidance on developing obesity drugs and strengthening coordinated scientific research to reduce obesity and to develop foods that are healthier and low in calories. In 2007, FDA partnered with the Cartoon Network to launch Spot the Block, a media campaign targeted at ‘tweens’ that seeks to educate children on how to better use the Nutrition Facts label. The program’s objective is to “combat childhood obesity by empowering ‘tweens’ to look for and use the Nutrition Facts on the food label.”511 The FDA also reviews drugs and medical devices that are used for medical management of obesity. Health Resources and HRSA seeks to expand health care for all Americans and is structured to focus on specific populations. Services Administration The Maternal and Child Health Bureau (MCHB) coordinates several obesity-related programs, (HRSA) including one component of the Bright Futures initiative and the National Adolescent Health Information Center (NAHIC). The President’s FY 2009 budget proposes to cut HRSA’s total program level by almost $1 billion, from $6.916 billion in FY 2008, to $5.921 billion.512 That includes a $39 million reduction in maternal and child health programs, from $849 million in FY 2008 to $809 million in FY 2009. Indian Health Service The mission of the Indian Health Service (IHS) is “to elevate the health status of American Indian and (IHS) Alaska Natives (AI/AN) to the highest possible level.”513 Large disparities remain between the general U.S. population and the American Indian/ Native Alaskan population. For instance, one in 5 American Indian/ Alaskan Native children are overweight compared to one in 5 children in the general U.S. population. Many of the obesity prevention initiatives are funded via IHS’s Hospitals and Health Clinics’ public and community health initiatives, such as Health Promotion and Disease Prevention, which counts obesity and physical activity and exercise as 2 of its primary prevention focus areas, and the Chronic Care Initiative. The President’s FY 2009 proposed budget for Hospitals and Health Clinics seeks $1.522 billion, an increase of $37.9 million from FY 2008.514 National Institutes of In FY 2007, NIH funded $661 million in obesity research. The complexity of obesity -- both its Health (NIH) causes and treatments -- led to the creation of the Obesity Research Task Force, which implements the Strategic Plan for NIH Obesity Research. The Plan focuses on 4 areas: lifestyle modification; medical approaches; linkages between obesity and health, specifically the detection of biomarkers and other molecular factors that serve as early warning signs for the development of obesity-related health problems; and health disparities among certain racial, ethnic, and socioeconomic populations.515 The Plan coordinates research across all 25 NIH Institutes, Centers, and Offices. Research studies examine clinical and population-based outcomes across the short-, intermediate-, and the long-term. Given the complexity of obesity research, it is difficult to gauge how much money NIH spends on obesity-related research each year. However, on obesity research alone, NIH’s FY 2009 professional budget estimate is $658 million, $2 million less than in FY 2008. 123 AGENCY INITIATIVES/PROGRAMS National Institutes of We Can! (Ways to Enhance Children’s Activity & Nutrition) is a national program designed Health (NIH) as a one-stop resource for parents and caregivers interested in practical tools to help children 8-13 years old stay at a healthy weight. Tips and fun activities focus on three critical behaviors: improved food choices, increased physical activity and reduced screen time. The program is a collaboration of 4 Institutes of the National Institutes of Health (NIH): the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the National Institute of Child Health and Human Development (NICHD) and the National Cancer Institute (NCI). National Institutes of Media-Smart Youth: Eat, Think, and Be Active! is an interactive after-school education Health (NIH) program for young people ages 11 to 13. It is designed to help teach them about the complex media world around them, and how it can affect their health -- especially in the areas of nutrition and physical activity. This program was created by the National Institute of Child Health and Human Development (NICHD). Office of Disease The Office of Disease Prevention and Health Promotion (ODPHP) develops and Prevention and Health coordinates a wide range of national disease prevention and health promotion strategies. Together Promotion with the U.S. Department of Agriculture (USDA), ODPHP publishes the Dietary Guidelines for Americans every 5 years. The Office is also responsible for setting national health goals via the Healthy People reports. Issued every 10 years, ODPHP is currently in the early phases of developing Healthy People 2020. Office of the Surgeon The Surgeon General is America’s preeminent health educator, providing leadership and General management of public health and advocating for scientifically credible and healthy lifestyle directions.516 The position has been filled by Acting Surgeon General Steven K. Galson since 2006, when President Bush failed to renew the 4-year term of then Surgeon General Richard Carmona. Acting Surgeon General Galson has made childhood obesity a top prevention priority of his tenure. In November 2007, his office launched the “Childhood Overweight and Obesity Prevention Initiative, Healthy Youth for a Healthy Future,” which targets overweight and obesity prevention and promotes healthy lifestyles for children.517 The initiative includes checklists for parents and caregivers, schools and teachers, and communities to help children be physically active and support healthy eating habits. Office of Women’s OWH sponsors a number of initiatives related to obesity prevention and control, including the Health (OWH) WOMAN Challenge, or Women and girls Out Moving Across the Nation. The WOMAN Challenge is a free 8-week challenge that encourages women and girls to walk 10,000 steps or get 30 minutes of moderate exercise every day.518 Now in its ninth year, The WOMAN Challenge is launched in May to coincide with National Women’s Health Week. The president’s FY 2009 proposed budget for OWH is $28 million, a $3 million decrease from FY 2008. President’s Council on The President’s Council on Physical Fitness and Sports was established in 1956 by President Physical Fitness and Dwight D. Eisenhower after a study found American children less fit than European youths. Sports (PCPFS) The Council, which is a group of 20 members appointed to serve at the pleasure of the president, advises the president through the Secretary of Health and Human Services about physical activity, sports and overall fitness. The Council also recommends programs, supports health initiatives, and collaborates with public and private sector groups to emphasize the importance of regular physical activity and fitness, for Americans of all ages and abilities. PCPFS is housed at HHS and advises the President and Secretary of HHS on ways to encourage more Americans to become physically fit and active. The PCPFS communicates with the public on the importance of exercise; increases physical activity participation and opportunities by encouraging related efforts in schools and communities; collaborates with business, industry, government and labor organizations on innovative programs to reduce the financial and health care costs associated with physical inactivity; and cooperates with medical, dental and other allied health care professional associations to encourage patient counseling on physical activity and fitness habits and practices. 124 U.S. Department of HUD’s mission is to increase home ownership, support community development and increase Housing and Urban access to affordable housing free from discrimination. As part of its mission, HUD works to Development (HUD) improve the living environment of low-income Americans. AGENCY PROGRAM/INITIATIVES The Community Development Block Grant (CDBG) program provides communities with resources to address a wide range of unique community development needs. Grants can be used to develop viable communities by providing decent housing, a suitable living environment, and opportunities to expand economic opportunities. CDBG funds can be used for park and recreation projects which can affect physical activity. The president’s FY 2009 budget contains $3 billion for the CDBG program, a $866 million decrease from FY 2008. U.S. Department of The Department of the Interior is the nation’s principal conservation agency responsible for the Interior protecting federal lands and managing natural resources. Parks and open spaces provide opportuni- ties for Americans to engage in physical activity. AGENCY PROGRAM/INITIATIVES Bureau of Land The Take it Outside: Children and Nature Initiative is a new initiative to “to encourage more Management children and their families to spend more time outdoors on the public lands; to improve the overall health of our Nation’s children; and to promote stewardship of the public lands.”519 The budget for this program is minimal at $225,000. National Parks Service The National Parks Service undertook a review of its assets and resources in 2006 in order to address the role NPS can play in promoting and providing healthy recreational activities. The report “Health, Recreation and Our National Parks” details the many ways NPS can offer opportunities for Americans’ to improve their overall fitness and health520 NPS has developed a number of programs and initiatives to foster healthy living, several of which are detailed below. The president’s FY 2009 budget requests $2.1 billion, an increase of $160.9 million from FY 2008. National Parks Service The Land and Water Conservation Fund (LWCF)’s goal is to “meet state and locally identified public outdoor recreation resources needs to strengthen the health and vitality of the American People.”521 The federal program awards grant monies to state and local governments and solicits matching dollar amounts from state and local governments, as well as the private sector, to acquire land for recreation, develop new recreation facilities, and improve existing facilities. In FY 2008, LWCF awarded $23 million in grants.522 However, the president’s FY 2009 budget zeroes out these funds for LWCF State Assistance grants. Instead, revenues from the management of the Outer Continental Shelf will be used for Stateside LWCF Grants. FY 2009 is the first year of this new arrangement and the president’s budget request is for $6.3 billion. National Parks Service Healthy Parks/ Healthy Living “is a park-based program intended to promote the daily recreational benefits inherent in urban national parks and encourage local park visitors to participate in healthy activities and outdoor recreational opportunities in a manner that supports the agency’s mission of stewardship.”523 National Parks Service The Rivers, Trails, and Conservation Assistance Program helps local groups plan and develop new trails, greenways, and open space that are close to home and encourage regular physical activity.524 The program offers technical assistance to community groups, nonprofits and local, state, and federal government agencies to conserve rivers, preserve open space, and develop trails and greenways. FY 2007 funding for this initiative was about $8.3 million. The president’s FY 2009 budget reduces this program by $314,000. 125 Office of Personnel OPM is responsible for building a high-quality and diverse federal workforce, based on merit and Management system principles. This is accomplished by recruiting citizens to federal service, connecting job applicants with federal agencies and departments, and administering retirement, health benefits, long-term care, and life insurance programs. AGENCY PROGRAM/INITIATIVES In an effort to reduce the demands on the health care system and associated costs, OPM manages the HealthierFeds initiative, which educates the federal civilian workforce and retirees about healthy living and best health care strategies. In partnership with Federal Employees Health Benefits Program (FEHB) carriers, OPM runs a web site that offers practical information on nutrition, physical activity, and prevention (http://www.healthierfeds.opm.gov/) The FEHB, like Medicare and Medicaid, is a federal program that is bearing the ever-increasing health care costs associated with obesity. In FY 2009 the program is expected to cover over 8 million federal employees, annuitants, and their dependents and pay out benefits of $37.4 billion, an increase of $2.3 billion from FY 2008. According to a 2003 study, every additional 30-minute time period a person spends in a car each day translates into a 3 percent greater chance of being obese.525 U.S. Department of The Department of Transportation’s mission is to “serve the United States by ensuring a fast, safe, Transportation (DOT) efficient, accessible and convenient transportation system that meets our vital national interests and enhances the quality of life of the American people, today and into the future.”526 AGENCY PROGRAM/INITIATIVES Federal Highway Safe Routes to School provides funding for programs and projects such as building safer street Administration crossings and establishing programs that encourage children and their parents to walk and bicycle safely to school. The president’s FY 2009 budget request for this program is $183 million, up $33 million from FY 2008. Federal Highway The Pedestrian Road Show is a toolkit DOT put together to help communities identify and Administration address their pedestrian safety problems and build more walk-able communities. Federal Highway Transportation Enhancements Activities are federally funded, community-based projects that Administration expand travel choices and enhance the transportation experience by improving the cultural, historic, aesthetic and environmental aspects of our transportation infrastructure.527 The federal government reimburses up to 80 percent of the cost of approved TE programs. There are 12 eligible activities that qualify for the TE program. Of these 12 there are several that could arguably promote physical activity: I Provision of pedestrian and bicycle facilities; I Provision of pedestrian and bicycle safety and education activities; I Acquisition of scenic or historic easements and sites; I Rehabilitation and operation of historic transportation buildings, structures, or facilities; and I Conversion of abandoned railway corridors to trails. The president’s FY 2009 budget request for this program is $660 million. Federal Highway The Non-motorized Transportation Pilot Program, part of the 2005 Transportation Bill, Administration established programs in 4 U.S. communities (Columbia, Missouri; Marin County, California; Minneapolis-St. Paul, Minnesota; and Sheboygan County, Wisconsin.) to develop a “network of non-motorized transportation infrastructure facilities, including sidewalks, bicycle lanes, and pedestrian and bicycle trails, that connect directly with transit stations, schools, residences, businesses, recreation areas, and other community activity centers.”528 Each community can receive $6.25 million in grant money each year for this project. Funding has remained constant at $25 million per fiscal year since FY2006.529 126 U.S. Department of The Treasury Department is responsible for promoting economic prosperity and ensuring the Treasury financial security of the United States. Among the Treasury Department’s responsibilities is the regu- lation of financial markets and tax collection. AGENCY PROGRAM/INITIATIVES In the area of tax collection and the tax code, the Department of Treasury is able to issue rulings clar- ifying tax deductions. In fact, in 2002 the Treasury Department issued Revenue Ruling 2002-19 which changed the philosophy of the Internal Revenue Service by allowing weight-loss program deductions for obesity and as a treatment for hypertension.530 The Treasury Department did not go as far as to extend the tax deduction for exercise programs that are recommended by physicians to foster weight loss among obese and overweight patients. The VA serves over 6 million veterans; nearly 70 percent are overweight, of whom approximately 30 percent are obese.531 U.S. Department of The U.S. Department of Veterans Affairs provides patient care and federal benefits to veterans Veterans Affairs (VA) and their dependents. AGENCY PROGRAM/INITIATIVES The VA together with HHS implements HealthierUS Veterans, a program to educate veterans about the health risks of obesity and diabetes. One component of the HealthierUS Veterans initiative is the MOVE! (Managing Overweight/Obesity for Veterans Everywhere) Program. The MOVE! Program is a weight management and physical activity initiative designed for veterans enrolled in the VA health care system who want assistance with managing their weight. The program relies on evidence-based methods that focus on behavior, nutrition, and physical activity. VA primary care providers give each veteran enrolled in MOVE! a pedometer, a brochure that explains how to use the pedometer, and an exercise prescription for recommended physical activity, such as a number of daily steps to walk. All providers have been encouraged to give their patients similar activity guidance.532 127 References 14 Serdula, M.K., D. Ivery, R.J. Coates, D.S. Freedman, D.F. Williamson, and T. Byers. “Do Obese Children become Obese Adults? A Review of the Literature.” 1 U.S. Centers for Disease Control and Prevention. “Overweight and Obesity - Introduction.” U.S. Preventive Medicine 22, no.2 (1993):167-177. Department of Health and Human Services. 15 U.S. Centers for Disease Control and Prevention. http://www.cdc.gov/nccdphp/dnpa/obesity/ind “Overweight and Obesity - Consequences.” U.S. ex.htm (accessed June 17, 2008). Department of Health and Human Services. 2 U.S. Centers for Disease Control and Prevention, http://www.cdc.gov/nccdphp/dnpa/obesity/ National Center for Health Statistics. “Prevalence childhood/consequences.htm (accessed June of Overweight and Obesity Among Adults: United 17, 2008). States, 2003-2004.” U.S. Department of Health and 16 U.S. Centers for Disease Control and Prevention. Human Services. http://www.cdc.gov/nchs/ “Preventing Obesity and Chronic Diseases products/pubs/pubd/hestats/overweight/overwg through Good Nutrition and Physical Activity.” ht_adult_03.htm (accessed June 17, 2008). U.S. Department of Health and Human Services, 3 U.S. Department of Health and Human Services, http://www.cdc.gov/nccdphp/publications/ National Center for Health Statistics. Prevalence of factsheets/Prevention/obesity.htm. (accessed Overweight Among Children and Adolescents: United April 14, 2008). States, 1999. Hyattsville, MD: National Center for 17 Ogden, C.L., M.D. Carroll, and K.M. Flegal. “High Health Statistics; 2001. http://www.cdc.gov/ Body Mass Index for Age among U.S. Children and nchs/products/pubs/pubd/hestats/overwght99. Adolescents, 2003-2006.” Journal of the American htm..(accessed July 14, 2008). Medical Association 299, no. 20 (2008): 2401-2405. 4 Ogden, C.L., M.D. Carroll, and K.M. Flegal. “High 18 Wang, Y. and M.A. Beydoun. “The Obesity Body Mass Index for Age among U.S. Children and Epidemic in the United States - Gender, Age, Adolescents, 2003-2006.” Journal of the American Socioecononomic, Racial/Ethnic, and Medical Association 299, no. 20 (2008): 2401-2405. Geographic Characteristics: A Systematic 5 Gregg, E.W., J. Yiling, B.L. Cadwell, et al. Review and Meta-Regression Analysis.” “Secular Trends in Cardiovascular Disease Risk Epidemiologic Reviews 29 (2007): 6-28. Factors According to Body Mass Index in US 19 U.S. Food and Drug Administration. “The Facts Adults.” Journal of the American Medical Association about Weight Loss Products and Programs.” U.S. 293, no. 15 (2005): 1868-1874. Department of Health and Human Services. 6 National Institutes of Diabetes and Digestive and http://www.cfsan.fda.gov/~dms/wgtloss.html Kidney Diseases. “Do You Know the Health Risks (accessed June 5, 2008). of being Overweight?” U.S. Department of Health 20 The CPT code set, maintained by the American and Human Services. Medical Association, is used by physicians and http://win.niddk.nih.gov/publications/health_ris other health care providers to bill for medical ks.htm (accessed April 18, 2007). services and procedures. Obesity-related 7 American Heart Association and American HCPCS (Health Care Financing Administration Stroke Association. Heart Disease and Stroke Common Procedure Coding Systems) Level II Statistics - 2008 Update. Dallas, TX: American codes were also selected. These codes are used Heart Association, 2008. for products, supplies, and services not includ- ed in the CPT codes but often covered by 8 Beydoun, M.A., H.A. Beydoun, and Y. Wang. Medicare and other insurers. “Obesity and Central Obesity as Risk Factors for Incident Dementia and Its Subtypes: A Systematic 21 U.S. Centers for Disease Control and Prevention, Review and Meta-Analysis.” Obesity Review 9, no. 3 National Center on Vital Statistics. Health, United (2008): 204-218. States, 2003. Atlanta, GA: U.S. Department of Health and Human Services, 2003. 9 Petry, N. M., D. Barry, R. H. Pietrzak, and J. A. Wagner. “Overweight and Obesity Are Associated 22 Ibid. with Psychiatric Disorders: Results from the 23 Stunkard, A. J. and T. A. Wadden, eds. Obesity: National Epidemiologic Survey on Alcohol and Theory and Therapy. Second ed. New York, NY: Related Conditions.” Psychosomatic Medicine 70, Raven Press, 1993. no. 3 (2008): 288-297. 24 National Research Council. Diet and Health: 10 Wang, Y., X. Chen, Y. Song, B. Caballero, and Implications for Reducing Chronic Disease Risk. L.J. Cheskin. “Association between Obesity and Washington, D.C.: National Academy Press, 1989. Kidney Disease: A Systematic Review and Meta- 25 Ibid. Analysis.” Kidney International 73, no. 1 (2008): 26 Barlow, S.E. “Expert Committee 19-33. Recommendations Regarding the Prevention, 11 Trust for America’s Health. Healthy Women: The Assessment, and Treatment of Child and Path to Healthy Babies, The Case for Preconception Adolescent Overweight and Obesity: Summary Care. Washington, D.C.: TFAH, 2008. Report.” Pediatrics 120, suppl 4 (2007): S164-S192. 12 American Diabetes Association. “Total Prevalence 27 Squires, S. “One Number Doesn’t Fit All.” The of Diabetes & Pre-Diabetes.” American Diabetes Washington Post. July 5, 2005. Association. http://diabetes.org/diabetes-statis- 28 Ibid. tics/prevalence.jsp (accessed April 18, 2008). 29 Ibid. 13 Whitaker, R.C., J.A. Wright, M.S. Pepe, K.D. Seidel, and W.H. Dietz. “Predicting Obesity in 30 Parker-Pope, T. “Watch Your Girth.” The New Young Adulthood from Childhood and Parental York Times, May 13, 2008. Obesity.” New England Journal of Medicine 37, no. 31 Ibid. 13 (1997): 869-873. 32 Ibid. 128 33 Freedman, D. S., L. K. Khan, M. K. Serdula, W. 46 Cowie, C.C., K.F. Rust, D.D. Byrd-Hold, et al. H. Dietz, S. R. Srinivasan, and G. S. Berenson. “Prevalence of Diabetes and Impaired Fasting “The Relation of Childhood BMI to Adult Glucose in Adults in the U.S. Population: National Adiposity: The Bogalusa Heart Study.” Pediatrics Health and Nutrition Examination Survey 1999- 115, no. 1 (2005): 22-27. 2002.” Diabetes Care 29, no. 6 (2006): 1263-1268. 34 Freedman, D. S., H. S. Kahn, Z. Mei, L. M. 47 Ibid. Grummer-Strawn, W. H. Dietz, S. R. Srinivasan, 48 U.S. Centers for Disease Control and Prevention. and G. S. Berenson. “Relation of Body Mass Index “Number of People with Diabetes Continues to and Waist-to-Height Ratio to Cardiovascular Increase.” U.S. Department of Health and Disease Risk Factors in Children and Adolescents: Human Services. http://cdc.gov/Features/ The Bogalusa Heart Study.” The American Journal DiabetesFactSheet/ (accessed June 26, 2008). of Clinical Nutrition 86, no. 1 (2007): 33-40. 49 U.S. Centers for Disease Control and Prevention. 35 Must, A., J. Spadano, E. H. Coakley, A. E. Field, CDC Protecting Health for Life: The State of the CDC, G. Colditz, and W. H. Dietz. “The Disease Fiscal Year 2004. Atlanta, GA: U.S. Department of Burden Associated with Overweight and Health and Human Services, 2005. Obesity.” The Journal of the American Medical Association 282, no. 16 (1999): 1523-1529. 50 U.S. Centers for Disease Control and Prevention. “Number of People with Diabetes Continues to 36 Parker-Pope, T. “Watch Your Girth.” The New Increase.” U.S. Department of Health and York Times, May 13, 2008. Human Services. http://cdc.gov/Features/ 37 American Medical Association (AMA). Expert DiabetesFactSheet/ (accessed June 26, 2008). Committee Recommendations on the Assessment, 51 Narayan, K. M., J. P. Boyle, L. S. Geiss, J. B. Prevention, and Treatment of Child and Adolescent Saaddine, and T. J. Thompson. “Impact of Over weight and Obesity. Chicago, IL: AMA, 2007, Recent Increase in Incidence on Future http://www.ama-assn.org/ama1/pub/upload/ Diabetes Burden: U.S., 2005-2050.” Diabetes Care mm/433/ped_obesity_recs.pdf (accessed 29, no. 9 (Sep, 2006): 2114-2116. April 22, 2008). 52 American Diabetes Association. “Total Prevalence 38 Ogden, C.L., M.D. Carroll, and K.M. Flegal. of Diabetes & Pre-Diabetes.” American Diabetes “High Body Mass Index for Age among U.S. Association. http://diabetes.org/diabetes-statis- Children and Adolescents, 2003-2006.” Journal tics/prevalence.jsp (accessed April 18, 2008). of the American Medical Association 299, no. 20 (2008): 2401-2405. 53 Ibid. 39 Ebbeling, C.B. and D.S. Ludwig. “Tracking 54 The Diabetes Prevention Program Research Pediatric Obesity: An Index of Uncertainty?” Group. “The Diabetes Prevention Program.” Journal of the American Medical Association 299, Diabetes Care 25, no. 12 (2002): 2165-2171. no. 20 (2008): 2442-2443. 55 U.S. Centers for Disease Control and Prevention. 40 U.S. Department of Health and Human Services, “National Diabetes Fact Sheet - General Infor- Health Resources and Services Administration, mation.” U.S. Department of Health and Human Maternal and Child Health Bureau. National Services. http://www.cdc.gov/diabetes/pubs/ Survey of Children’s Health 2003. Rockville, MD: general05.htm#what (accessed April 21, 2008). U.S. Department of Health and Human Services, 56 Kaufman, F.R. “Type 2 Diabetes in Children and 2005, http://www.mchb.hrsa.gov/overweight/ Young Adults: A ‘New Epidemic’.” Clinical techapp.htm (accessed April 22, 2008). Diabetes 20, no. 4 (October 1, 2002): 217-218. 41 U.S. Centers for Disease Control and 57 Ibid. Prevention. “Youth Risk Behavior Surveillance - 58 American Diabetes Association. “Preventing - United States, 2007.” Morbidity and Mortality Type 2 Diabetes in Children and Teens.” Diabetes Weekly Report 57, no. SS-4 (2008): 1-136. Spectrum 18, no. 4 (October 1, 2005): 249-250. 42 Polhamus, B., K. Dalenius, E. Borland, B. Smith, 59 Cavallo, J. “Who Has Diabetes?” Juvenile Diabetes and L. Grummer-Strawn. Pediatric Nutrition Research Foundation Countdown (Spring 2006): 10-19. Surveillance 2006 Report. Atlanta, GA: U.S. 60 Writing Group for the SEARCH for Diabetes in Department of Health and Human Services, Youth Study Group, D. Dabelea, R. A. Bell, R. B. Centers for Disease Control and Prevention, 2007. D’Agostino Jr, G. Imperatore, J. M. Johansen, B. 43 Ezzati, M., H. Martin, S. Skjold, S. Vander Linder, et al. “Incidence of Diabetes in Youth in Hoorn, and C. J. Murray. “Trends in National the United States.” The Journal of the American and State-Level Obesity in the USA after Medical Association 297, no. 24 (2007): 2716-2724. Correction for Self-Report Bias: Analysis of 61 Kaufman, F.R. “Type 2 Diabetes in Children and Health Surveys.” Journal of the Royal Society of Young Adults: A ‘New Epidemic’.” Clinical Medicine 99, no. 5 (May, 2006): 250-257. Diabetes 20, no. 4 (October 1, 2002): 217-218. 44 Putnam, J., J. Allshouse, and L. S. Kantor. “U.S. 62 American Diabetes Association. “Total Prevalence per Capita Food Supply Trends: More Calories, of Diabetes & Pre-Diabetes.” American Diabetes Refined Carbohydrates, and Fats.” Food Review Association. http://diabetes.org/diabetes-statis- 25, no. 3 (2002): 1-14. tics/prevalence.jsp (accessed April 18, 2008). 45 National Institutes of Diabetes and Digestive and 63 U.S. Department of Health and Human Services, Kidney Diseases. “Do You Know the Health Risks of Office of Disease Prevention and Health Promotion. being Overweight?” U.S. Department of Health and “Physical Activity and Fitness-Improving Health, Human Services. http://win.niddk.nih.gov/publica Fitness, and Quality Of Life through Daily Physical tions/health_risks.htm (accessed April 18, 2007). Activity.” Prevention Report, 16, no. 4 (July 2002): 1-15. http://odphp.osophs.dhhs.gov/pubs/prevrpt/02V olume16/Iss4Vol16.pdf (accessed May 12, 2008). 129 64 American Heart Association. Heart Disease and 83 Daniels, S.R., F.R. Greer and the Committee on Stroke Statistics - 2006 Update. Dallas, TX: Nutrition. “Lipid Screening and Cardiovascular American Heart Association, 2006. Health in Childhood.” Pediatrics 122, no. 1 65 Ibid. (2008): 198-208. 66 National Institutes of Diabetes and Digestive and 84 U.S. Department of Health and Human Kidney Diseases. “Do You Know the Health Risks Services (USDHHS). The Surgeon General’s Call to of being Overweight?” U.S. Department of Health Action to Prevent and Decrease Overweight and and Human Services. http://win.niddk.nih.gov/ Obesity. Washington, D.C.: USDHHS, 2001. publications/health_risks.htm (accessed April 18, 85 Ibid. 2007). 86 Levine, S., B. Maloney, B. Schulte, and R. Stein. 67 Ibid. “How Obesity Harms a Child’s Body.” The 68 The Obesity Society. “Obesity Statistics - U.S. Washington Post, May 18, 2008. Trends.” The Obesity Society. 87 American College of Obstetricians and http://www.obesity.org/statistics/obesity_trends Gynecologists. Adolescents and Obesity - A Resource .asp (accessed April 18, 2008). Guide. Washington, D.C.: American College of 69 National Institutes of Diabetes and Digestive and Obstetricians and Gynecologists, 2007. Kidney Diseases. “Do You Know the Health Risks http://www.acog.org/departments/Adolescent of being Overweight?” U.S. Department of Health HealthCare/AdolescentsandObesity.pdf and Human Services. http://win.niddk.nih.gov/ (accessed May 28, 2008). publications/health_risks.htm (accessed April 18, 88 Trust for America’s Health. Healthy Women: The 2007). Path to Healthy Babies, The Case for Preconception 70 U.S. Centers for Disease Control and Prevention. Care. Washington, D.C.: TFAH, 2008. “Obesity in the News: Helping Clear the Confusion.” 89 U.S. Centers for Disease Control and Power Point Presentation, May 25, 2005. Prevention. “Recommendations to Improve 71 American Cancer Society. Cancer Facts and Figures Preconception Health and Health Care-United 2007. Atlanta, GA: American Cancer Society, 2007. States.” Morbidity and Mortality Weekly Report 55, no. 4 (2006): RR-6. 72 U.S. Centers for Disease Control and Prevention. “Obesity in the News: Helping Clear the Confusion.” 90 Chu, S.Y., D.J. Bachman, W.M. Callaghan, et al. Power Point Presentation, May 25, 2005. “Association between Obesity during Pregnancy and Increased Use of Health Care.” New England 73 Beydoun, M.A., H.A. Beydoun, and Y. Wang. Journal of Medicine 358, no. 14, (April 2008): “Obesity and Central Obesity as Risk Factors for 1444-1453. Incident Dementia and Its Subtypes: A Systematic Review and Meta-Analysis.” Obesity 91 Ibid. Review 9, no. 3 (2008): 204-218. 92 U.S. Department of Health and Human Services 74 Petry, N. M., D. Barry, R. H. Pietrzak, and J. A. and U.S. Department of Agriculture. Dietary Wagner. “Overweight and Obesity Are Guidelines for Americans, 2005. 6th Edition, Associated with Psychiatric Disorders: Results Washington, D.C.: U.S. Government Printing from the National Epidemiologic Survey on Office, 2005 Alcohol and Related Conditions.” Psychosomatic 93 Centers for Disease Control and Prevention. Medicine 70, no. 3 (2008): 288-297. Physical Activity for Everyone. http://www.cdc.gov/ 75 Ibid. nccdphp/dnpa/physical/everyone/recommendat ions/older_adults.htm (accessed July 1, 2008). 76 Wang, Y., X. Chen, Y. Song, B. Caballero, and L.J. Cheskin. “Association between Obesity and Kidney 94 U.S. Department of Health and Human Disease: A Systematic Review and Meta-Analysis.” Services and U.S. Department of Agriculture. Kidney International 73, no. 1 (2008): 19-33. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government 77 Ibid. Printing Office, January 2005 78 Felson, D.T., and Y. Zhang. “An Update on the 95 U.S. Centers for Disease Control and Epidemiology of Knee and Hip Osteoarthritis Prevention. Behavioral Risk Factor Surveillance with a View to Prevention.” Arthritis and System Survey Data. Atlanta, GA: U.S. Department Rheumatism 41, no. 8 (1998):1343-1355. of Health and Human Services, 2006. 79 U.S. Centers for Disease Control and Prevention. 96 U.S. Centers for Disease Control and Prevention. “NHIS Arthritis Surveillance.” U.S. Department of Behavioral Risk Factor Surveillance System Survey Health and Human Services. http://www.cdc.gov/ Data . Atlanta, GA: U.S. Department of Health arthritis/data_statistics/national_data_nhis.htm#e and Human Services, 2005. xcess (accessed June 26, 2008). 97 Blair, S.N. “The Importance of Fitness in Children 80 Warner, J. “Small Weight Loss Takes Big and Adults.” Presentation at the IOM Annual Pressure off Knee.” WebMD Health News. Meeting, October 16, 2000. http://www.iom.edu/ http://www.webmd.com/osteoarthritis/news/2 CMS/7622/7625.aspx (accessed April 18, 2008). 0050629/small-weight-loss-takes-pressure-off- knee (accessed June 26, 2008). 98 U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control 81 Ogden, C.L., M.D. Carroll, and K.M. Flegal. and Prevention, National Center for Chronic “High Body Mass Index for Age among U.S. Disease Prevention and Health Promotion, and Children and Adolescents, 2003-2006.” Journal Division of Nutrition and Physical Activity. Promoting of the American Medical Association 299, no. 20 Physical Activity: A Guide for Community Action. Vol. 1. (2008): 2401-2405. Champaign, IL: Human Kinetics, 1999. 82 Institute of Medicine (IOM). Childhood Obesity in the United States: Facts and Figures. 130 Washington, D.C.: IOM, September 2004. 99 U.S. Centers for Disease Control and Prevention. 121 Amy, N.K., A. Aalborg, P. Lyons, and L “Trends in Leisure-Time Physical Inactivity by Keranen. “Barriers to Routine Gynecological Age, Sex, and race/ethnicity—United States, Cancer Screening for White and African- 1994-2004.” Morbidity and Mortality Weekly Report American Obese Women.” International Journal 54, no. 39 (Oct 7, 2005): 991-994. of Obesity 30, no. 1 (2006): 147-155. 100 U.S. Department of Health and Human 122 Olson, C.L., H.D. Schumaker, and B.P Yawn. Services, Public Health Service, Centers for “Overweight Women Delay Medical Care.” Disease Control and Prevention, National Archives of Family Medicine 3, no. 10 (1994): 888-892. Center for Chronic Disease Prevention and 123 Fontaine, K.R., M.S. Faith, D.B. Allison, and L.J Health Promotion, and Division of Nutrition Cheskin. “Body Weight and Health Care among and Physical Activity. Promoting Physical Activity: Women in the General Population.” Archives of A Guide for Community Action. Vol. 1. Family Medicine, 7, no. 4 (1998): 381-384. Champaign, IL: Human Kinetics, 1999. 124 Rand, C.S., and A.M. Macgregor. “Morbidly Obese 101 Ibid. Patients’ Perceptions of Social Discrimination 102 Nader, P.R., R.H. Bradley, R.M. Houts, S. L. Before and After Surgery for Obesity.” Southern McRitchie, and M. O’Brien. “Moderate-to- Medical Journal 83, no. 12 (1990): 1398-1395. Vigorous Physical Activity from Ages 9 to 15 125 Schwimmer J.B., T.M. Burwinkle, and J.W. Years.” Journal of the American Medical Association Varni. “Health-Related Quality of Life of 300, no. 3 (2008): 295-305. Severely Obese Children and Adolescents.” 103 U.S. Centers for Disease Control and Journal of the American Medical Association 289, Prevention. “Youth Risk Behavior Surveillance no. 14 (2003): 1851-1853. -- United States, 2007.” Morbidity and Mortality 126 U.S. Department of Health and Human Weekly Report 57, no. SS-4 (2008): 1-136. Services and U.S. Department of Agriculture. 104 Ibid. Dietary Guidelines for Americans, 2005. 6th 105 Ibid. Edition, Washington, D.C.: U.S. Government Printing Office, 2005 106 Ibid. 127 McGinnis, M. J. Obesity: An American Public Health 107 Ibid. Epidemic, Strategies to Better Understand it and Change 108 Exercise is Medicine. A Newsletter Promoting the America’s Behavior. Washington, D.C.: National Benefits of Activity. Volume 1, Spring 2008. Institute for Health Care Management, 2004. 109 Andreyeva, T., R. Puhl, and K.D. Brownell. 128 Putnam, J., J. Allshouse, and L. S. Kantor. “U.S. “Changes in Perceived Weight Discrimination per Capita Food Supply Trends: More Calories, among Americans: 1995-1996 through 2004- Refined Carbohydrates, and Fats.” Food Review 2006.” Obesity 16, no. 5 (2008):1129-1134. 25, no. 3 (2002): 1-14. 110 Roehling, M.V., P.V. Roehling, and S. Pichler. 129 U.S. Centers for Disease Control and Prevention. “The Relationship between Body Weight and “Trends in Intake of Energy and Macronutrients Perceived Weight-Related Employment Discrim- —United States, 1971-2000.” Morbidity and ination: The Role of Sex and Race.” Journal of Mortality Weekly Report 53, no. 4 (2004): 80-82. Vocational Behavior, 71, no. 2 (2007): 300-318. 130 Briefel, R. R. and C. L. Johnson. “Secular 111 Pingitore, R., R. Dugoni, S. Tindale, and B. Trends in Dietary Intake in the United States.” Spring. “Bias against Overweight Job Applicants Annual Review of Nutrition 24, (2004): 401-431. in a Simulated Employment Interview.” Journal 131 Nielsen, S. J. and B. M. Popkin. “Patterns and of Applied Psychology 79, no. 6 (1994): 909-917. Trends in Food Portion Sizes, 1977-1998.” 112 Baum, C.L. and W.F. Ford. “The Wage Effects Journal of the American Medical Association 289, of Obesity: A Longitudinal Study.” Health no. 4 (2003): 450-453. Economics 13, no. 9 (2004):885-899. 132 Putnam, J., J. Allshouse, and L. S. Kantor. 113 Rudd Center for Food Policy and Obesity. “U.S. per Capita Food Supply Trends: More Weight Bias: The Need for Public Policy. New Calories, Refined Carbohydrates, and Fats.” Haven, CT: Yale University, 2008. Food Review 25, no. 3 (2002): 1-14. 114 Ibid. 133 Ibid. 115 Neumark-Sztainer, D., M. Story, and T. Harris. 134 Ibid. “Beliefs and Attitudes about Obesity among 135 Ibid. Teachers and School Health Care Providers Working with Adolescents.” Journal of Nutrition 136 Ibid. Education 31, no. 1 (1999): 3-9. 137 Cleveland, L. National Food Consumption Survey, 116 O’Brien, K.S., J.A. Hunter, and M. Banks. “Implicit 1977-78. Washington, D.C.: U.S. Department Anti-Fat Bias in Physical Educators: Physical of Agriculture, 1979. Attributes, Ideology, and Socialisation.” International 138 U.S. Centers for Disease Control and Prevention, Journal of Obesity 31, no. 2 (2007): 308-314. National Center for Health Statistics. “DHHS- 117 Canning, H. and J. Mayer. “Obesity-Its Possible USDA Dietary Survey Integration - What We Eat in Effects on College Acceptance.” New England America.” U.S. Department of Health and Human Journal of Medicine 275 (1966): 1172-1174. Services, http://www.cdc.gov/nchs/about/major/ nhanes/faqs.htm (accessed April 18, 2008). 118 Rudd Center for Food Policy and Obesity. Weight Bias: The Need for Public Policy. New 139 U.S. Centers for Disease Control and Prevention, Haven, CT: Yale University, 2008. National Center for Health Statistics. Health, United States, 2007: With Chartbook on Trends in the 119 Ibid. Health of Americans. Washington, D.C.: U.S. 120 Ibid. Department of Health and Human Services, 2007. 131 140 Ibid. 159 Gordian Health Solutions. Managing the 141 Segal, D. “Objects on Your Plate May Be Obesity Problem: A Case Study with Measurable Smaller Than They Appear.” The Washington Results. Nashville, TN: Gordian Health Post, April 13, 2008. Solutions, 2007. 142 Pollan, M. “Supersize Me Organically.” The New 160 Wang, F., T. McDonald, L. J. Champagne, and Farm. http://www.newfarm.org/features/2005/ D. W. Edington. “Relationship of Body Mass 0805/pollen/index2_print.shtml. (accessed Index and Physical Activity to Health Care Costs May 22, 2008). among Employees.” Journal of Occupational and Environmental Medicine 46, no. 5 (2004): 428-436. 143 Ibid. 161 Burton, W. N., C. Y. Chen, A. B. Schultz, and D. 144 Martin, A. “Will Diners Swallow This?” The W. Edington. “The Economic Costs Associated New York Times, March 25, 2007. with Body Mass Index in a Workplace.” Journal 145 Ibid. of Occupational and Environmental Medicine 40, 146 U.S. Centers for Disease Control and no. 9 (1998): 786-792. Prevention, National Center for Health 162 Xiang, H., G. A. Smith, J. R. Wilkins, G. Chen, Statistics. “Calorie Consumption on the Rise S. G. Hostetler, and L. Stallones. “Obesity and in United States, Particularly Among Women.” Risk of Nonfatal Unintentional Injuries.” News Release, February 5, 2004. American Journal of Preventive Medicine 29, no. 1 http://www.cdc.gov/nchs/PRESSROOM/04ne (2005): 41-45. ws/calorie.htm (accessed May 22, 2008). 163 Ostbye, T., J. M. Dement, and K. M. Krause. 147 Martin, A. “Will Diners Swallow This?” The “Obesity and Workers’ Compensation: Results New York Times, March 25, 2007. from the Duke Health and Safety Surveillance 148 Ibid. System.” Archives of Internal Medicine 167, no. 8 (2007): 766-773. 149 U.S. Centers for Disease Control and Prevention. “Preventing Obesity and Chronic Diseases 164 Ibid. Through Good Nutrition and Physical Activity.” 165 Berger, E. “Emergency Departments Shoulder U.S. Department of Health and Human Services, Challenges of Providing Care, Preserving http://www.cdc.gov/nccdphp/publications/ Dignity for the ‘Super Obese.’” Annals of factsheets/Prevention/obesity.htm. (accessed Emergency Medicine 50, no. 4 (2007): 443-445. April 14, 2008). 166 Zezima, K. “Increasing Obesity Requires New 150 Ibid. Ambulance Equipment.” The New York Times, 151 Rosen, B. and L. Barrington. Weights & Measures: April 8, 2008. What Employers Should Know about Obesity. New 167 Ibid. York, NY: The Conference Board, April 2008. 168 Berger, E. “Emergency Departments Shoulder 152 Ibid. Challenges of Providing Care, Preserving 153 Ostbye, T., J. M. Dement, and K. M. Krause. Dignity for the ‘Super Obese.’” Annals of “Obesity and Workers’ Compensation: Results Emergency Medicine 50, no. 4 (2007): 443-445. from the Duke Health and Safety Surveillance 169 Foreman, C.T. Remarks made as moderator of System.” Archives of Internal Medicine 167, no. 8 the panel “Changing the Food Environment,” (2007): 766-773. part of the Transatlantic Public Policy 154 The Robert Wood Johnson Foundation, the Approaches to Tackling Obesity and Diet- American Stroke Association, and the Related Disease conference held in American Heart Association. A Nation at Risk: Washington, D.C. on April 8, 2008. Obesity in the United States, A Statistical Sourcebook. 170 Lyons, A.A., J. Park, and C. H. Nelson. “Food Dallas, TX: American Heart Association, 2005. Insecurity and Obesity: A Comparison of Self- http://www.americanheart.org/downloadable/ Reported and Measured Height and Weight.” heart/1114880987205NationAtRisk.pdf American Journal of Public Health 98, no. 4 (accessed April 14, 2008). (2008): 751-757. 155 Pronk, N. P., B. Martinson, R. C. Kessler, A. L. 171 Monsivais, P., and A. Drewnowski. “The Rising Beck, G. E. Simon, and P. Wang. “The Cost of Low-Energy-Density Foods.” Journal of Association between Work Performance and the American Dietetic Association 107, no. 12 Physical Activity, Cardiorespiratory Fitness, and (2007): 2017-2076. Obesity.” Journal of Occupational and 172 Ibid. Environmental Medicine 46, no. 1 (2004): 19-25. 173 Lubrano, A. “Food Costs Likely to Boost Obesity 156 Ostbye, T., J. M. Dement, and K. M. Krause. in Poor.” Philadelphia Inquirer, May 6, 2008. “Obesity and Workers’ Compensation: Results from the Duke Health and Safety Surveillance 174 K. Downey. “Hunger Pains: As Economy Slows, System.” Archives of Internal Medicine 167, no. 8 Charities Face Tall Order to Feed Needy.” The (2007): 766-773. Washington Post, B01, April 8, 2008. 157 Pronk, N. P., B. Martinson, R. C. Kessler, A. L. 175 Ibid. Beck, G. E. Simon, and P. Wang. “The 176 Booth, M., C. Chirico, B. Edwards, and K. Association between Work Performance and Gramp. Monthly Budget Review Fiscal Year 2008: A Physical Activity, Cardiorespiratory Fitness, and Congressional Budget Office Analysis. Washington, Obesity.” Journal of Occupational and D.C.: Congressional Budget Office, 2008, Environmental 46, no. 1 (2004): 19-25. http://www.cbo.gov/ftpdocs/90xx/doc9023/03 158 Aldana, S. G. and N. P. Pronk. “Health Promotion -2008-MBR.pdf (accessed April 16, 2008). Programs, Modifiable Health Risks, and 177 Eckholm, E. “As Jobs Vanish and Prices Rise, Employee Absenteeism.” Journal of Occupational Food Stamp Use Nears Record.” The New York 132 and Environmental 43, no. 1 (2001): 36-46. Times, March 31, 2008. 178 Food and Nutrition Service. “Women, Infants, http://www.pde.state.pa.us/food_nutrition/lib/f and Children.” U.S. Department of Agriculture. ood_nutrition/nutrition_guidelines_r_3_- http://www.fns.usda.gov/wic/ (accessed April final.pdf (accessed July 23, 2008). 16, 2008). 193 Wharton, C.M., M. Long, and M.B. Schwartz. 179 Parham, P. Written Testimony of Penny Parham, “Changing Nutrition Standards in Schools: The Administrative Director, Department of Food and Emerging Impact on School Revenue.” Journal Nutrition, Miami-Dade County, Florida, Public of School Health 78, no. 5 (2008): 245-252. Schools Before the Committee on Education and Labor 194 Ibid. United States House of Representatives. Miami, FL: Miami-Dade County Public Schools, March 4, 195 U.S. Department of Agriculture, Food and 2008. http://edlabor.house.gov/testimony/ Nutrition Service, Office of Research, 2008-03-04-PennyParham.pdf Nutrition and Analysis. School Nutrition Dietary Assessment Study-III, Vol. I: School Foodservice, 180 Ibid. School Food Environment, and Meals Offered and 181 Glod, M. “Schools Get a Lesson in Lunch Line Served. Alexandria, VA: USDA, 2007. Economics: Food Costs Unravel Nutrition Init- 196 Ibid. iatives.” The Washington Post, A01, April 14, 2008. 197 Finkelstein, D.M., E.L. Hill, and R.C. Whitaker. 182 Hecht, K. Testimony before the Committee on “School Food Environments and Policies in Education and Labor, House of Representatives. San U.S. Public Schools.” Pediatrics 122, no. 1 Francisco, CA: California Food Policy Advocates, (2008): e251-e259. (E-pub ahead of print.) 2008, http://edlabor.house.gov/testimony/ 2008-03-04-KennethHecht.pdf (accessed April 198 U.S. Department of Agriculture, Food and 16, 2008). Nutrition Service. Foods Sold in Competition with USDA School Meal Programs: A Report to Congress. 183 U.S. Centers for Disease Control and Prevention. Washington, D.C.: U.S. Department of “CDC’s State Based Nutrition and Physical Activity Agriculture, 2001. http://www.fns.usda.gov/ Program to Prevent Obesity and other Chronic cnd/Lunch/CompetitiveFoods/report_congress Diseases.” U.S. Department of Health and .htm (accessed April 25, 2008). Human Services. http://www.cdc.gov/nccdphp/ dnpa/obesity/state_programs/index.htm. 199 Ibid. (accessed April 15, 2008). 200 U.S. Government Accountability Office (GAO). 184 Ibid. School Meal Programs: Competitive Foods Are Widely Available and Generate Substantial Revenues for 185 Utah Department of Health, Bureau of Health Schools. Washington, D.C.: GAO, 2005. Promotion. Tipping the Scales Toward a Healthier http://www.gao.gov/new.items/d05563.pdf Population: The Utah Blueprint to Promote Healthy (accessed May 28, 2008). Weight for Children, Youth, and Adults. Salt Lake City, UT: Utah Department of Health, 2006. 201 Center for Science in the Public Interest http://health.utah.gov/obesity/docs/Blueprin (CSPI). State School Foods Report Card 2007. t.pdf. (accessed April 9, 2008). Washington, D.C.: CSPI, 2007. 186 Arkansas Department of Health. Changing the 202 Institute of Medicine. Nutrition Standards for Culture of Health in Arkansas: A Coordinated Foods in Schools: Leading the Way Toward Healthier Approach to Health Promotion and Prevention of Youth. Washington, D.C.: National Academies Chronic Diseases and Related Complications. Little Press, 2007. Rock, AR: Arkansas Department of Health, 2005. 203 Wharton, C.M., M. Long, and M.B. Schwartz. http://www.healthyarkansas.com/disease/chroni “Changing Nutrition Standards in Schools: The c_disease_plan2006.pdf. (accessed April 3, 2008). Emerging Impact on School Revenue.” Journal 187 Veugelers, P.J. and A.L. Fitzgerald. of School Health 78, no. 5 (2008): 245-252. “Effectiveness of School Programs in 204 Ibid. Preventing Childhood Obesity: A Multilevel 205 Institute of Medicine. Preventing Childhood Comparison.” American Journal of Public Health Obesity: Health in the Balance. Washington, D.C.: 95, no. 3 (2005): 432-435. The National Academies Press, 2005. 188 U.S. Department of Agriculture (USDA). 206 Menschik, D., S. Ahmed, M. H. Alexander, and Incorporating the 2005 Dietary Guidelines for R.W. Blum. “Adolescent Physical Activities as Americans into School Meals. SP 04-2008. Predictors of Young Adult Weight.” Archives of Washington, D.C.: USDA, 2007. Pediatrics Adolescent Medicine 162, no. 1 (2008): 189 Ibid. 29-33. 190 U.S. Department of Agriculture, Food and 207 Institute of Medicine. Preventing Childhood Nutrition Service, Office of Research, Obesity: Health in the Balance. Washington, D.C.: Nutrition and Analysis. School Nutrition Dietary The National Academies Press, 2005. Assessment Study-III, Vol. I: School Foodservice, 208 U.S. Centers for Disease Control and Prevention. School Food Environment, and Meals Offered and “Guidelines for School and Community Served. Alexandria, VA: USDA, 2007. Programs to Promote Lifelong Physical Activity 191 Wharton, C.M., M. Long, and M.B. Schwartz. Among Young People.” MMWR Recommendations “Changing Nutrition Standards in Schools: The and Reports 46, no. RR-6 (1997): 1-36. Emerging Impact on School Revenue.” Journal http://www.cdc.gov/mmwr/preview/mmwrhtml of School Health 78, no. 5 (2008): 245-252. /00046823.htm (accessed May 5, 2008). 192 Pennsylvania Department of Education, Division 209 American Academy of Pediatrics, Committee of of Food and Nutrition. Nutrition Standards for Sports Medicine and Fitness, and Committee on Competitive Foods in Pennsylvania Schools for the School School Health. “Physical Fitness and Activity in Nutrition Incentive. Harrisburg, PA: Pennsylvania Schools.” Pediatrics 105, no. 5 (2000): 1156-1157. Department of Education, July 27, 2007. 133 210 U.S. Centers for Disease Control and 227 Ibid. Prevention. “Youth Risk Behavior Surveillance 228 Foster, G. D., S. Sherman, K. E. Borradaile, et -- United States, 2007.” Morbidity and Mortality al. “A Policy-Based School Intervention to Weekly Report 57, no. SS-4 (2008): 1-136. Prevent Overweight and Obesity.” Pediatrics 211 Field, T., M. Diego, and C. E. Sanders. 121, no. 4 (2008): e794-802. “Exercise is Positively Related to Adolescents’ 229 This assessment does not include a compre- Relationships and Academics.” Adolescence 36, hensive review of all food tax policies in all no. 141 (2001): 105-110. states. Some states with a general food tax 212 Lee, S.M., C.R. Burgeson, J.E. Fulton, and C.G. that covers “junk food” may not be included Spain. “Physical Education and Physical in this evaluation. Activity: Results From the School Health 230 Center for Science in the Public Interest (CSPI). Policies and Programs Study 2006.” Journal of “CSPI to Urge Taxes on Junk Foods to Fund School Health 77, no. 8 (2007): 435-463. Health Campaigns.” News Release, May 25, 213 National Association for Sport and Physical 2000. http://www.cspinet.org/new/tax_ Education (NASPE). What Constitutes a Quality junkfood.html (accessed April 25, 2008). Physical Education Program? Reston, VA: 231 Finkelstein, E. A. and L. Zuckerman. The NASPE, 2003. Fattening of America: How the Economy Makes Us 214 Hillman, C. H., K. I. Erickson, and A. F. Kramer. Fat, If It Matters, and What to Do About It. “Be Smart, Exercise Your Heart: Exercise Effects Hoboken, NJ: John Wiley & Sons, Inc., 2008. on Brain and Cognition.” Nature Reviews 232 Brownell, K. D. “The Chronicling of Obesity: Neuroscience 9, no. 1 (2008): 58-65. Growing Awareness of its Social, Economic, 215 Shephard, R. J. “Response of Brain, Liver, and Political Contexts.” Journal of Health Politics, Kidney, and Other Organs and Tissues to Policy and Law 30, no. 5 (2005): 955-964. Regular Physical Activity.” Chap. 8, In Physical 233 Jacobson, M.H. and K.D. Brownell. “Small Activity and Health, edited by C. Bouchard, S. Taxes on Soft Drinks and Snack Foods to N. Blair and W. L. Haskell, 127-140. Promote Health.” American Journal of Public Champaign, IL: Human Kinetics, Inc., 2007. Health 90, no. 6 (2000): 854-857. 216 Shephard, R. J. “Habitual Physical Activity and 234 Mississippi Health Advocacy Program (MHAP). Academic Performance.” Nutrition Reviews 54, Removing the Grocery Tax on Healthy Foods as a no. 4, Pt 2 (1996): S32-6. Public Health Policy. Jackson, MS: MHAP, 2007. 217 Trost, S.G. Physical Education, Physical Activity 235 Monsivais, P., and A. Drewnowski. “The Rising and Academic Performance: Research Brief. San Cost of Low-Energy-Density Foods.” Journal of the Diego, CA: Active Living Research, Robert American Dietetic Association 107, no. 12 (2007): Wood Johnson Foundation, 2007. 2017-2076. 218 Ibid 236 The American Medical Association. “AMA 219 Carlson, S. A., J. E. Fulton, S. M. Lee, et al. Adopts Policies to Promote Healthier Food “Physical Education and Academic Achievement Options to Fight Obesity in America.” News in Elementary School: Data from the Early Release, June 27, 2007. http://www.ama- Childhood Longitudinal Study.” American assn.org/ama/pub/category/17768.html Journal of Public Health 98, no. 4 (2008): 721-727. (accessed May 27, 2008). 220 Shephard, R. J. “Habitual Physical Activity and 237 National Restaurant Association. 2007 State Academic Performance.” Nutrition Reviews 54, Legislative Session Summary. Washington, D.C.: no. 4, Pt 2 (1996): S32-6. National Restaurant Association, 2007. 221 Castelli, D., C.H. Hillman, S.M. Buck, and H.E. 238 Center for Science in the Public Interest (CSPI). Erwin. “Physical Fitness and Academic Nutrition Labeling in Chain Restaurants -- State and Achievement in Third- and Fifth-Grade Local Bills/Regulations - 2007-2008. Washington, Students.” Journal of Sport and Exercise D.C.: CSPI, 2008. http://www.cspinet.org/ Psychology 29, no. 2 (2007): 239-252. nutritionpolicy/MenuLabelingBills2007- 222 Nelson, M.C., and P. Gordon-Larsen. “Physical 2008.pdf (accessed May 27, 2008). Activity and Sedentary Behavior Patterns Are 239 Ibid. Associated with Selected Adolescent Health Risk 240 The Rudd Center for Food Policy and Obesity. A Behaviors.” Pediatrics 117, no. 4 (2006): 1281-1290. Case Study of California’s Menu Labeling Legislation. 223 Trost, S.G. Physical Education, Physical Activity New Haven, CT: Yale University, 2008. and Academic Performance: Research Brief. San http://www.yaleruddcenter.org/what/policy/pdf Diego, CA: Active Living Research, Robert s/CaliforniaSB120MenuLabelCaseStudy.pdf Wood Johnson Foundation, 2007. (accessed May 27, 2008). 224 Coe, D.P., J.M. Pivarnik, C.J. Womack, M.J. 241 Center for Science in the Public Interest (CSPI). Reeves, and R.M. Malina. “Effect of Physical Nutrition Labeling in Chain Restaurants -- State and Education and Activity Levels on Academic Local Bills/Regulations - 2007-2008. Washington, Achievement in Children.” Medicine and Science D.C.: CSPI, 2008. http://www.cspinet.org/ in Sports and Exercise 38, no. 8 (2006): 1515-1519. nutritionpolicy/MenuLabelingBills2007-2008.pdf 225 CARDIAC WV Project. “Methods.” CARDIAC (accessed May 27, 2008). WV Project. http://www.cardiacwv.org/ 242 Arizona Department of Health Services. “Arizona methods.htm (accessed May 27, 2008). Smart Choice Program - Criteria for Approved 226 The Associated Press. “Screening Shows Menu Items.” Arizona Department of Health Obesity Down Among W. Va. Children.” The Services. http://www.azsmartchoice.com/Criteria Associated Press, May 22, 2008. AppovMenu.htm (accessed May 27, 2008). 134 243 Center for Science in the Public Interest (CSPI). 258 Ewing R., Forinash C., and Schroeer W. “Neigh- Anyone’s Guess. The Need for Nutrition Labeling at borhood Schools and Sidewalk Connections: Fast-Food and Other Chain Restaurants. What Are the Impacts on Travel Mode Choice Washington, D.C.: CSPI, 2003. and Vehicle Emissions?” Transportation Research http://www.cspinet.org/restaurantreport.pdf News 237 (March-April 2005): 1-7. (accessed May 27, 2008). http://onlinepubs.trb.org/Onlinepubs/trnews/t 244 National Restaurant Association. “House Vote to rnews237environment.pdf (April 30, 2008). Prevent Frivolous Lawsuits Against Restaurants, 259 Staunton, C.E., D. Hubsmith, and W. Kallins. Food Manufacturers: Just Plain Common “Promoting Safe Walking and Biking to School: Sense.” Press Release, March 10, 2004. The Marin County Success Story.” American Journal http://www.restaurant.org/pressroom/print/in of Public Health 93, no. 9 (2003): 1431-1434. dex.cfm?ID=833 (accessed April 25, 2008). 260 Patch, D. “Three Communities Get $422,400 245 Hulse, C. “Vote in House Offers a Shield in in State Grants for Sidewalks.” Toledo Blade, Obesity Suits.” New York Times, March 11, 2004. January 23, 2008. 246 Center for Science in the Public Interest (CSPI). 261 Wisniewski, M. “Feds Foot Bill So Kids Can Walk “‘Big Food’ to Win Special Protection in House to School.” The Chicago Sun-Times, March 7, 2008. of Representatives.” News Release, March 10, 262 California Department of Transportation. 2004. http://www.cspinet.org/new/ “Caltrans Awards $52 Million in Safe Routes to 200403102.html (accessed April 25, 2008). School Funding.” Press Release, March 18, 2008. 247 109th Congress. Healthy Places Act of 2007. http://www.dot.ca.gov/hq/paffairs/news/pressr S.1067. 2nd sess. (March 29, 2007) and 109th el/08pr4.htm (accessed May 2, 2008). Congress. Healthy Places Act of 2007. H.R. 398. 263 “North Coast Communities Receive Safe Routes 2nd sess. (February 2, 2007). to School Funding.” The Eureka Reporter, March 248 McCann, B. and R. Ewing. Measuring the Health 29, 2008, http://www.eurekareporter.com/ Effects of Sprawl: A National Analysis of Physical article/080329-communities-get-safe-routes-to- Activity, Obesity, and Chronic Disease. Washington, school-funding (accessed May 2, 2008). D.C.: Smart Growth America and the Surface 264 For example, a law may fix a standard or direct Transportation Policy Project, 2003. an administrative agency to adopt one or a www.smartgrowthamerica.org/report/HealthSp potential range of standards through an rawl8.03.pdf (accessed April 25, 2008). administrative process. 249 Prevention Institute. Improving the Nutrition and 265 Cleveland Clinic. “Laparoscopic Weight Loss Physical Activity Environment in California. Surgery.” http://my.clevelandclinic.org/services/ Oakland, CA: Prevention Institute, 2002. laparoscopic_surgery/hic_laparoscopic_weig http://preventioninstitute.org/nutrition_ ht_loss_surgery.aspx (accessed July 2, 2008). PA.html. (accessed April 25, 2008). 266 Newswise. “Insurance Coverage for Obesity is 250 U.S. Department of Health and Human Services. a Model for the Nation.” Healthy People 2010. 2nd Edition. Washington, http://www.newswise.com/p/articles/view/50 D.C.: U.S. Government Printing Office, 2000. 7650. (accessed July 2, 2008). 251 McDonald, N. C. “Active Transportation to 267 Mant, D. “Effectiveness of Dietary Intervention School: Trends among U.S. Schoolchildren, in General Practice.” American Journal of Clinical 1969-2001.” American Journal of Preventive Nutrition 65, no. Suppl 6 (1997):1933S-1938S. Medicine 32, no. 6 (2007): 509-516. 268 Newswise. “Insurance Coverage for Obesity is 252 U.S. Centers for Disease Control and a Model for the Nation.” Prevention. “Barriers to Children Walking and http://www.newswise.com/p/articles/view/50 Biking to School—United States, 1999.” 7650. (accessed July 2, 2008). Morbidity and Mortality Weekly Report 51, no. 32 (2002): 701-704. 269 Ibid. 253 Powell, K. E., L. Martin, and P. P. Chowdhury. 270 Heubeck, E. “Reimbursement Offers Hope for “Places to Walk: Convenience and Regular More Obesity Counseling: New Pay Programs/ Physical Activity.” American Journal of Public AMA Guidelines Could Fuel the Fight Against Health 93, no. 9 (2003): 1519-1521. Pediatric Obesity. DOC News 4, no. 9 (September 2007). http://docnews.diabetesjournals.org/ 254 Giles-Corti, B. and R. J. Donovan. “The cgi/content/full/4/9/8 (accessed July 2, 2008). Relative Influence of Individual, Social, and Physical Environment Determinants of 271 Ibid. Physical Activity.” Social Science & Medicine 54, 272 Ibid. no. 12 (2002): 1793-1812. 273 Goldfarb, B. “Medicare Issues Bariatric Surgery 255 Robert Wood Johnson Foundation. Grant Results: Policy Guidelines.” DOC News, May 2006. Researchers Review State Policies on Promoting http://docnews.diabetesjournals.org/cgi/re Walking and Biking - Identify Five with Greatest print/3/5/1-a.pdf (accessed July 2, 2008). Potential to Work. Princeton, NJ: RWJF, 2005, 274 Ibid. http://www.rwjf.org/reports/grr/046958.htm 275 Barlow, S.E. and the Expert Committee. (accessed April 10, 2008). “Expert Committee Recommendations 256 110th Congress. Complete Streets Act of 2008. S. Regarding the Prevention, Assessment, and 2686. 2nd sess. (March 3, 2008). Treatment of Child and Adolescent 257 McDonald, N. C. “Active Transportation to Overweight and Obesity: Summary Report.” School: Trends among U.S. Schoolchildren, Pediatrics 120, Suppl 4 (2007): S164-S192. 1969-2001.” American Journal of Preventive Medicine 32, no. 6 (2007): 509-516. 135 276 U.S. Department of Health and Human Services. September 2007. http://www.ers.usda.gov/ “HHS Announces Revised Medicare Obesity Publications/CCR34/CCR34.pdf (accessed Coverage Policy.” News Release, July 15, 2004. June 3, 2008). http://www.hhs.gov/news/press/2004pres/2004 292 Richardson, J. Child Nutrition and WIC Programs: 0715.html (accessed July 14, 2008). Background and Recent Funding. Washington, D.C.: 277 StateHealthFacts.org. “Total Medicaid Congressional Research Service, The Library of Enrollment, FY2005.” Kaiser Family Foundation. Congress, 2006. http://statehealthfacts.org/comparemaptable. 293 Ibid. jsp?ind=198&cat=4 (accessed July 14, 2008). 294 U.S. Department of Agriculture. Farm Bill: Title 278 Doering, C. “USDA Revises Food Program for IV Nutrition. Washington, D.C.: USDA, 2007. Women and Children.” Reuters, December 6, 2007. 295 Ibid. 279 Institute of Medicine. WIC Food Packages: Time 296 Sisson, A. “Fruit and Vegetable Consumption for a Change. Washington, D.C.: The National by Low-Income Americans.” Nutrition Noteworthy Academies Press, 2005. 5, no. 1 (2002): 1-7. 280 Daniels, P., D. Whitford, A. Bartholomew and P. 297 Cotterill, R.W. and A.W. Franklin. The Urban Mitchell. “The New WIC Food Packages.” Grocery Store Gap. Hartford, CT: Storrs Food Presentation at the National WIC Association’s Marketing Policy Center, University of 18th Annual Washington Leadership Conference Connecticut, 1995. and WIC Food Package Implementation Summit. 298 Morris, P. M. Higher Prices, Fewer Choices: Shopping Washington, D.C., March 11, 2008. for Food in Rural America. Washington, D.C.: 281 Ibid. Public Voice for Food and Health Policy, 1990. 282 Information provided to TFAH by the National 299 Putnam, J., J. Allshouse, and L.S. Kantor. “U.S. WIC Association during a meeting at TFAH Per Capita Food Supply Trends: More Calories, offices on April 17, 2008. Refined Carbohydrates, and Fats.” Food Review 25, no. 3 (2002): 1-14. 283 U.S. Centers for Disease Control and Prevention. “Breastfeeding Practices - Results 300 Institute for Agriculture and Trade Policy. Food from the National Immunization Survey.” U.S. without Thought: How U.S. Farm Policy Contributes Department of Health and Human Services. to Obesity. Minneapolis, MN: Institute for http://www.cdc.gov/breastfeeding/data/NIS_ Agriculture and Trade Policy, 2006. data/data_2004.htm (accessed May 2, 2008). 301 Richardson, J. Child Nutrition and WIC 284 Womenshealth.gov. “Health Risks of Not Legislation in the 108th and 109th Congresses. Breastfeeding.” U.S. Department of Health and Washington, D.C.: Congressional Research Human Services. http://www.4woman.gov/ Service, The Library of Congress, 2006. Breastfeeding/index.cfm?page=519 (accessed 302 National Coalition for Promoting Physical May 2, 2008). Activity. Letter to Congress Concerning No Child 285 United States Department of Agriculture. Left Behind Legislation. June 12, 2007. (USDA) “Food Stamp Program Participation and 303 Jeffrey, R.W. and J. Utter. “The Changing Costs.” USDA. http://www.fns.usda.gov/pd/ Environment and Population Obesity in the fssummar.htm (May 9, 2008). United States.” Obesity Research 11, Suppl (2003): 286 Baum, C. The Effects of Food Stamps on Obesity. 12S-22S. Washington, D.C.: Economic Research Service, 304 Ross, R. and I. Janssen. “Physical Activity, United States Department of Agriculture, Fitness, and Obesity.” Chap. 11, In Physical September 2007. http://www.ers.usda.gov/ Activity and Health, edited by C. Bouchard, S. Publications/CCR34/CCR34.pdf (accessed N. Blair and W. L. Haskell. 1st ed. Vol. 1, 173- June 3, 2008). 189. Champaign, IL: Human Kinetics, 2007. 287 Ver Ploeg, M., L. Mancino, and B.H. Lin. Food 305 Hedley, A.A., C.L. Ogden, C.L. Johnson, M.D. and NutritionAssistance Programs and Obesity: 1976- Carroll, L.R. Curtin, and K.M. Fegal. “Prevalence 2002. Washington, D.C.: Economic Research of Overweight and Obesity Among U.S. Children, Service, USDA, 2007. http://www.ers.usda.gov/ Adolescents, and Adults; 1999-2002.” Journal of the Publications/ERR48/ERR48.pdf (May 9, 2008). American Medical Association 292, no. 23 (2004): 288 Baum, C. The Effects of Food Stamps on Obesity. 2847-2850. Washington, D.C.: Economic Research Service, 306 Haskell, W. L., S. N. Blair, and C. Bouchard. United States Department of Agriculture, “An Integrated View of Physical Activity, Fitness September 2007. http://www.ers.usda.gov/ and Health.” Chap. 23, In Physical Activity and Publications/CCR34/CCR34.pdf (accessed Health, edited by C. Bouchard, S. N. Blair and June 3, 2008). W. L. Haskell. Vol. 1, 359-374. Champaign, IL: 289 American Heart Association. “American Heart Human Kinetics, 2007. Association Meeting Report: People on Food 307 U.S. Department of Transportation, Bureau of Stamps Can’t Afford Heart-Healthy Meals -- Transportation Statistics. National Survey of Abstract 3698.” News Release, November 9, 2004. Pedestrian and Bicyclist Attitudes and Behaviors 290 Center for Science in the Public Interest Highlights Report. Washington, D.C.: U.S. (CSPI). “Policy Options to Promote Nutrition Department of Transportation, 2002. and Activity.” CSPI. http://www.cspinet.org/ 308 Girl Scouts. “Girl Scouts and Congresswoman nutritionpolicy/policy_options.html Mary Bono Join Forces to Support Children’s 291 Baum, C. The Effects of Food Stamps on Obesity. Health.” News Release, June 13, 2007. Washington, D.C.: Economic Research Service, http://www.girlscouts.org/news/news_releases/2 United States Department of Agriculture, 007/healthy_living.asp (accessed June 3, 2008). 136 309 GovTrack.us. H.R. 2677—110th Congress (2007): 325 Katzmarzyk, P.T. and I. Janssen. “The Economic IMPACT Act, GovTrack.us (database of federal legisla- Costs Associated with Physical Inactivity and tion)http://www.govtrack.us/congress/bill.xpd?bill Obesity in Canada: An Update.” Canadian =h110-2677&tab=summar (accessed Jun 3, 2008). Journal of Applied Physiology 29 (2004): 90-115. 310 GovTrack.us. “H.R. 3895—110th Congress (2007): 326 Pescatello, L.S., B.A. Franklin, R. Fagard, W.B. MEAL Act”. GovTrack.us (database of federal legisla- Farquhar, G.A. Kelley, and C.A. Ray. tion)http://www.govtrack.us/congress/bill.xpd?bill “American College of Sports Medicine Position =h110-3895&tab=summary (accessed Apr 22, 2008) Stand: Exercise and Hypertension.” Medicine 311 110th Congress. Complete Streets Act of 2008. S. and Science in Sports and Exercise 36 (2004): 533- 2686. 2nd sess. (March 3, 2008). 553. 312 Note: Some U.S. Centers for Disease Control 327 Alcazar, O., R.C. Ho, and L.J. Goodyear. “Physical and Prevention suggest the use of the term Activity, Fitness and Diabetes Mellitus.” Chap. 21, “cooperative agreement” and others suggest In Physical Activity and Health, edited by C. the use of the term “grant” for these programs. Bouchard, S. N. Blair and W. L. Haskell. Vol. 1, 191-204. Champaign, IL: Human Kinetics, 2007. 313 U.S. Centers for Disease Control and Prevention. “CDC’s State-Based Nutrition and Physical 328 Institute of Medicine. Progress in Preventing Child- Activity Program to Prevent Obesity and Other hood Obesity: How Do We Measure Up? Washington, Chronic Diseases.” U.S. Department of Health D.C.: The National Academies Press, 2007. and Human Services. http://www.cdc.gov/ 329 Ibid. nccdphp/dnpa/obesity/state_programs/index.h 330 Institute of Medicine. Preventing Childhood tm (accessed June 3, 2008). Obesity: Health in the Balance. Washington, D.C.: 314 U.S. Centers for Disease Control and The National Academies Press, 2005. Prevention. “Our Mission: Four Strategies to 331 Institute of Medicine. Progress in Preventing Child- Promote National School Health.” U.S. hood Obesity: How Do We Measure Up? Department of Health and Human Services. Washington, D.C.: The National Academies http://www.cdc.gov/HealthyYouth/about/mis Press, 2007. sion.htm (accessed June 3, 2008). 332 Institute of Medicine. Preventing Childhood 315 U.S. Centers for Disease Control and Obesity: Health in the Balance. Washington, D.C.: Prevention (CDC). Steps to a HealthierUS The National Academies Press, 2005. Program: Preventing Chronic Diseases Through Local Community Action. Atlanta, GA: CDC, 2007. 333 U.S. Department of Housing and Urban Development. Interim Survey of Children. 316 U.S. Centers for Disease Control and Prevention. Washington, D.C.: U.D. Department of Housing “FY 2009 Budget Submission Centers For Disease and Urban Development, 2001. Control And Prevention Discretionary All-Purpose http://www.huduser.org/ Table.” U.S. Department of Health and Human Research/IxIchildF.pdf (accessed April 30, 2008). Services. http://www.cdc.gov/fmo/PDFs/FY07- 09_Functional_Table.pdf (accessed May 28, 2008). 334 Abt Associates Inc. and the National Bureau of Economic Research. Moving to Opportunity Interim 317 Institute of Medicine. Preventing Childhood Impacts Evaluation. Washington, D.C.: U.S. Obesity: Health in the Balance. Washington, D.C.: Department of Housing and Urban Develop- The National Academies Press, 2005. ment, Office of Policy Development and 318 National Center for Health Statistics. Health, Research, 2003. United States, 2006 with Chartbook on Trends in the http://www.huduser.org/Publications/pdf/MTO Health of Americans. Hyattsville, MD: U.S. FullReport.pdf (accessed April 30, 2008). Government Printing Office, 2006. 335 Jones, B.H., M.W. Bovee, and J.J. Knapik. http://www.cdc.gov/nchs/data/hus/hus06.pdf “Associations among Body Composition, #073 (accessed April 28, 2008). Physical Fitness and Injury in Men and Women 319 Institute of Medicine. Preventing Childhood Army Trainees.” Chap. 9, In Body Composition Obesity: Health in the Balance. Washington, D.C.: and Physical Performance: Applications for the The National Academies Press, 2005. Military Services, edited by B. M. Marriott and J. 320 Institute of Medicine. Progress in Preventing Child- Grumstrup-Scott. Vol. 1, 141-174. Washington, hood Obesity: How Do We Measure Up? Washington, D.C.: National Academies Press, 1992. D.C.: The National Academies Press, 2007. 336 Hsu, L.L., R.L. Nevin, S.K. Tobler, and M.V. 321 U.S. Department of Health and Human Rubertone. “Trends in Overweight and Services. Healthy People 2010. 2nd Edition. Obesity among 18-Year-Old Applicants to the Washington, D.C.: U.S. Government Printing United States Military, 1993-2006.” The Journal Office, 2000. of Adolescent Health 41, no. 6 (2007): 610-612. 322 Office of the Surgeon General. The Surgeon 337 Basu, S. “Military Not Immune From Obesity General’s Call to Action to Prevent and Decrease Over- ‘Epidemic.’” U.S. Medicine, March 25, 2004. weight and Obesity. Rockville, MD: U.S. Department http://www.usmedicine.com/dailyNews.cfm?d of Health and Human Services, 2001. ailyID=187 (accessed May 1, 2008). 323 Perreault, L., Y. Ma, S. Dagogo-Jack, et al. “Sex 338 Hoffman, M. “55 Percent of Airmen Differences in Diabetes Risk and the Effect of Overweight.” Air Force Times, April 30, 2008. Intensive Lifestyle Modification in the Diabetes http://www.airforcetimes.com/news/2008/04/air Prevention Program.” Diabetes Care (Epub force_fat_AF_042808w/ (accessed April 30, 2008). ahead of print, Mar 20, 2008). 339 Cable News Network. “Discharged Servicemen 324 Kohl, H.W. “Physical Activity and Dispute Military Weight Rules.” CNN.com, Cardiovascular Disease: Evidence for a Dose September 6, 2000. http://www.cnn.com/ Response.” Medicine and Science in Sports and 2000/HEALTH/09/06/military.obesity/index.h Exercise 33, no. Suppl 6 (2001): S472-S483. tml (accessed May 2, 2008). 137 340 U.S. Department of Defense PharmacoEconomic 355 Ewing, R. and B. McCann. Measuring the Health Center. “Pharmacoeconomic Analysis of Obesity Effects of Sprawl: A National Analysis of Physical Treatment.” PEC Update 97, no. 5 (1997): 1-17. Activity, Obesity and Chronic Disease. Smart http://www.pec.ha.osd.mil/Updates/97%20PDF Growth America, Washington D.C., 2003. s/97-05.PDF (accessed June 4, 2008). http://www.smart-growthamerica.org/report/ 341 The average cost of recruiting and training a HealthSprawl8.03.pdf. (May 1, 2008). replacement enlisted member were adjusted 356 Simon, P., C.J. Jarosz, T. Kuo, and J.E. Fielding. for inflation for 2008 based on the change in Menu Labeling as a Potential Strategy for the Consumer Price Index (CPI) from fourth Combating the Obesity Epidemic: A Health Impact quarter 2006 to fourth quarter 2007. TFAH Assessment. Los Angeles, CA: Los Angeles used the Consumer Price Index calculation, County Department of Public Health, 2008. which is the inflation measure used by the U.S. 357 New York City Department of Health and Mental Department of Labor, Bureau of Labor Hygiene. “Board of Health Votes to Require Statistics. http://www.bls.gov/home.htm Chain Restaurants to Display Calorie Information (accessed June 4, 2008). in New York City.” Press Release, January 22, 342 Dall, T.M., Y. Zhang, Y.J. Chen, et al. “Cost Assoc- 2008. http://www.nyc.gov/html/doh/html/ iated with Being Overweight and with Obesity, pr2008/pr008-08.shtml (accessed May 1, 2008). High Alcohol Consumption, and Tobacco Use 358 The Associated Press. “New York Begins Citing within the Military Health System’s TRICARE Restaurants That Lack Calorie Counts on Prime-Enrolled Population.” American Journal of Menus.” The Associated Press, May 5, 2008. Health Promotion 22, no. 2 (2007): 120-139. 359 Saul, S. “Conflict on the Menu.” The New York 343 Freking, K. “Government to Unveil Fitness Test Times, February 16, 2008. for Adults.” The Associated Press, May 14, 2008. 360 Active Living by Design. “Active Seattle: 344 Ibid. Community Partnership.” Robert Wood 345 Center for Science in the Public Interest Johnson Foundation. (CSPI). “Why It’s Hard to Eat Well and Be http://www.activelivingbydesign.org/cgi- Active in America Today.” CSPI. bin/albd.org/view_services.cgi?request=show_pu http://www.cspinet.org/nutritionpolicy/food_ blic_home&dept_id=121 (accessed June 3, 2008). advertising.html (accessed May 14, 2008). 361 Moore, L. V. and A. V. Diez Roux. “Associations 346 Institute of Medicine. Progress in Preventing Child- of Neighborhood Characteristics with the hood Obesity: How Do We Measure Up? Washington, Location and Type of Food Stores.” American D.C.: The National Academies Press, 2007. Journal of Public Health 96, no. 2 (2006): 325-331. 347 Ibid. 362 Giang, T., A. Karpyn, H. Burton Laurison, A. 348 National Governors Association. Healthy Hiller, and R.D. Perry. “Closing the Grocery America: Wellness Where We Live, Work and Learn. Gap in Underserved Communities: The Call to Action: An Agenda for America’s Governors. Creation of the Pennsylvania Fresh Food Washington, D.C.: National Governors Financing Initiative.” Journal of Public Health Association, 2006. http://www.nga.org/Files/ Management Practice 14, no. 3 (2008): 272-279. pdf/0602HEALTHYAMCALL.PDF (accessed 363 Ibid. May 13, 2008). 364 Baker, E. A., M. Schootman, E. Barnidge, and C. 349 Institute of Medicine. Progress in Preventing Child- Kelly. “The Role of Race and Poverty in Access to hood Obesity: How Do We Measure Up? Washington, Foods that Enable Individuals to Adhere to D.C.: The National Academies Press, 2007. Dietary Guidelines.” Preventing Chronic Disease 3, 350 National Governors Association. Creating no. 3 (2006): A76. Healthy States: Actions for Governors. Washington, 365 Cubbin, C. and M.A. Winkleby. “Food D.C.: National Governors Association, 2006. Availability, Personal Constraints, and http://www.nga.org/Files/pdf/0602CREATIN Community Resources.” Journal of Epidemiology GHEALTHYSTATESACTIONS.PDF (accessed and Community Health 61, no. 11 (2007): 932. May 13, 2008.) 366 The Reinvestment Fund. “Bringing Super- 351 Institute of Medicine. Progress in Preventing Child- markets to Underserved Communities.” TRF. hood Obesity: How Do We Measure Up? Washington, http://www.trfund.com/stories/supermarkets.ht D.C.: The National Academies Press, 2007. ml (accessed May 5, 2008). 352 Ewing, R. and B. McCann. Measuring the Health 367 Shulman, R. “Groceries Grow Elusive For Effects of Sprawl: A National Analysis of Physical Many in New York City, With Rents Soaring, Activity, Obesity and Chronic Disease. Smart Growth Stores Are Being Demolished for Condos.” America, Washington D.C., 2003. The Washington Post, February 19, 2008. http://www.smart-growthamerica.org/report/ 368 Rivera, R. “Council Vote for Good Health May HealthSprawl8.03.pdf. (May 1, 2008). Weaken Business at Groceries in Poor Neighbor- 353 California Center for Public Health Advocacy, hoods.” The New York Times, February 28, 2008. PolicyLink, and the UCLA Center for Health 369 New Orleans Food Policy Advisory Committee. Policy Research. Designed for Disease: The Link Building Healthy Communities: Expanding Access to Between Local Food Environments and Obesity and Fresh Food Retail. New Orleans, LA: New Orleans Diabetes. Davis, CA: California Center for Food Policy Advisory Committee, 2007. Public Health Advocacy, 2008. http://www.no-hunger.org/news/FPAC-pr/ 354 Sallis, J. F. and K. Glanz. “The Role of Built REPORT%20FINAL.pdf (accessed May 5, 2008). Environments in Physical Activity, Eating, and 370 Troeh, E. “Food Shopping a Challenge in New Obesity in Childhood.” The Future of Children Orleans.” National Public Radio, March 28, 2007. 16, no. 1 (2006): 89-108. 371 Ibid. 138 372 Institute of Medicine. Preventing Childhood 392 Consumers Union. Out of Balance: Marketing of Obesity: Health in the Balance. Washington, D.C.: Soda, Candy, Snacks and Fast Foods Drowns Out The National Academies Press, 2005. Healthful Messages. San Francisco, CA: 373 Partnership to Fight Chronic Disease. Keeping Consumers Union, September 2005. America Healthy: A Guide to Successful Programs. 393 Center for Science in the Public Interest Washington, D.C. June 2008. (CSPI). “Why It’s Hard to Eat Well and Be 374 Story, M. K.M. Kaphingst, and S. French. “The Active in America Today.” CSPI. Role of Schools in Obesity Prevention.” The http://www.cspinet.org/nutritionpolicy/food_ Future of Children, 16, no. 1 (2006): 1-34. advertising.html (accessed May 14, 2008). 375 Gleason, P., C. Suitor, and U.S. Food and 394 Crain Communications Inc. and the Ad Age Nutrition Service. Children’s Diets in the Mid- Group. “50th Annual 100 Leading National 1990s: Dietary Intake and Its Relationship with School Advertisers.” Advertising Age, June 27, 2005. Meal Participation, Special Nutrition Programs, Report 395 Institute of Medicine. Food Marketing to Children no. CN-01-CD1. Alexandria, VA.: U.S. Dept of and Youth: Threat or Opportunity? Washington, Agriculture, Food and Nutrition Service, 2001. D.C.: The National Academies Press, 2006, p.5. 376 Brescoll, V.L., R. Kersh, and K.D. Brownell. 396 Crain Communications Inc. and the Ad Age “Assessing the Feasibility and Impact of Group. “50th Annual 100 Leading National Federal Childhood Obesity Policies.” The Advertisers.” Advertising Age, June 27, 2005. Annals of the American Academy of Political and 397 Hannaford Bros. “What is Guiding Stars?” Social Science 615, no. 1 (2008): 178-194. Hannaford Bros. http://www.hannaford.com/ 377 Nihiser, A.J., S.M. Lee, H. Wechsler, et al. “Body Contents/Healthy_Living/Guiding_Stars/index.s Mass Index Measurement in Schools.” The html (accessed May 29, 2008). Journal of School Health 77, no. 10 (2007):651-671. 398 Hannaford Bros. “Grocery Shoppers Are 378 Ibid. Following Stars to More Nutritious Choices.” 379 Institute of Medicine. Progress in Preventing Child- News Release, September 6, 2007. hood Obesity: How Do We Measure Up? Washington, 399 Ibid. D.C.: The National Academies Press, 2007. 400 Garson, A. and C.L. Engelhard. “Attacking 380 Ibid. Obesity: Lessons from Smoking.” Journal of the 381 Noguchi, Y. “Costs of Obesity Add to Business American College of Cardiology 49, no. 16 (2007): Overhead.” National Public Radio, May 23, 2008. 1673-1675. 382 Hertz, R.P., A.N. Unger, M. McDonald, M.B. 401 Ibid. Lustik, and J. Biddulph-Krentar. “The Impact of 402 Torrey Marshall, M. “Development of 2007 Farm Obesity on Work Limitations and Cardiovascular Bill: Prepared Statement by Maureen Torrey Risk Factors in the U.S. Workforce.” Journal of Marshall to the Committee on Agriculture, Occupational and Environmental Medicine 46, no. United States House of Representatives.” 12 (2004): 1196-1203. Washington, D.C.: United Fresh Produce 383 Institute of Medicine. Progress in Preventing Child- Association, June 26, 2006. hood Obesity: How Do We Measure Up? Washington, http://www.unitedfresh.org/assets/files/Mauree D.C.: The National Academies Press, 2007. n%20Torrey%20Marshall%202007%20Farm%20 Bill%20testimony.pdf (accessed May 14, 2008). 384 American Academy of Pediatrics. “Policy Statement: Breastfeeding and the Use of Human 403 Hamm, M. W. “Linking Sustainable Milk.” Pediatrics 115, no. 2 (2005): 496-506. Agriculture and Public Health: Opportunities for Realizing Multiple Goals.” Journal of Hunger 385 Ibid. and Environmental Nutrition (In Press): 1-14. 386 U.S. Department of Health and Human Services. 404 Ibid. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving 405 U.S. Food and Drug Administration. Food Protection Health. 2 vols. Washington, D.C.: U.S. Plan: An Integrated Strategy for Protecting the Nation’s Government Printing Office, November 2000. Food Supply. Washington, D.C.: U.S. Department of Health and Human Services, 2007. 387 Ryan A.S., W. Zhou, and M.B. Arensberg. “The Effect of Employment Status on 406 Institute for Agriculture and Trade Policy. Food Breastfeeding in the United States.” Women’s without Thought: How U.S. Farm Policy Contributes Health Issues 16, no. 5 (2006): 243-251. to Obesity. Minneapolis, MN: Institute for Agriculture and Trade Policy, March 2006. 388 National Conference of State Legislatures. “50 State Summary of Breastfeeding Laws - Updated 407 Green, L. W. and J. M. Ottoson. “From Efficacy April 2008.” National Conference of State to Effectiveness to Community and Back: Legislatures. http://www.ncsl.org/programs/ Evidence-Based Practice Vs Practice-Based health/breast50.htm (accessed May 13, 2008). Evidence.” Presented at the Conference From Clinical Trials to Community: The Science Of 389 Abdulwadud O.A. and M.E. Snow. “Interventions Translating Diabetes and Obesity Research, in the Workplace to Support Breastfeeding for Bethesda, MD, National Institutes of Health, Women in Employment.” Cochrane Database January 12-13, 2004, http://www.niddk.nih.gov/ System Review 18, no. 3 (2007):CD006177. fund/other/Diabetes-Translation/conf-publica- 390 Ibid. tion.pdf (accessed May 15, 2008). 391 Finkelstein, E. A. and L. Zuckerman. The 408 Schwartz, M.B. and Brownell, K.D. “Actions Fattening of America: How the Economy Makes Us Necessary to Prevent Childhood Obesity: Fat, If It Matters, and What to Do About It. Creating the Climate for Change.” Journal of Hoboken, NJ: John Wiley & Sons, Inc., 2008. Law, Medicine & Ethics 35, no. 1 ( 2007): 78-89. 139 409 George Washington Univesity School of Public 423 Ibid. Health and Health Services, Department of Health 424 Yancey, A.K. and S.K. Kumanyika. “Bridging the Policy. Re-Visioning Success: How Stigma, Perceptions Gap: Understanding the Structure of Social of Treatment, and Definitions of Success Impact Obesity Inequities in Childhood Obesity.” American Journal and Weight Management in America. A Research Report of Preventive Medicine 33, no. 4S (2007): S172-S174. for the STOP Obesity Alliance. Washington, D.C.: George Washington University, 2007. 425 Loukaitou-Sideris, A. “Crime Prevention and Active Living.” American Journal of Health 410 Ogden, C.L., M.D. Carroll, M.A. McDowell, Promotion 21, no. 4 Suppl (2007):380-389. and K.M. Flegal. Obesity among Adults in the United States- No Change Since 2003-2004. NCHS 426 Day, K. “Active Living and Social Justice: Plann- Data Brief No 1. Hyattsville, MD: National ing for Physical Activity in Low-Income, Black, Center for Health Statistics, 2007. and Latino Communities.” Journal of the American Planning Association 72, no. 1 (2006):88-99. 411 U.S. Centers for Disease Control and Prevention. “Youth Risk Behavior Surveillance 427 Bhattacharya, J., T. DeLeire, S. Heider, and J. -- United States, 2007.” Morbidity and Mortality Currie. “Heat or Eat? Cold-Weather Shocks and Weekly Report 57, no. SS-4 (2008): 1-136. Nutrition in Poor American Families.” American Journal of Public Health 93, no. 7 (2003):1149-54. 412 U.S. Department of Health and Human Services, Health Resources and Services Administration, 428 Day, K. “Active Living and Social Justice: Plann- Maternal and Child Health Bureau. National ing for Physical Activity in Low-Income, Black, Survey of Children’s Health 2003. Rockville, MD: and Latino Communities.” Journal of the American U.S. Department of Health and Human Services, Planning Association 72, no. 1 (2006):88-99. 2005, http://www.mchb.hrsa.gov/overweight/ 429 Kumanyika, S.K., M.C. Whitt-Glover, T.L. Gary, et techapp.htm (accessed April 22, 2008). al. “Expanding the Obesity Research Paradigm 413 Ogden, C.L., M.D. Carroll, L.R. Curtin, et al. to Reach African American Communities.” “Prevalence of Overweight and Obesity in the Preventing Chronic Disease 4, no. 4 (2007). United States, 1999-2004.” Journal of the American http://www.cdc.gov/pcd/issues/2007/oct/07_0 Medical Association 295, no. 13 (2006):1549-1555. 067.htm. (accessed June 6, 2008). 414 U.S. Centers for Disease Control and 430 The Henry J. Kaiser Family Foundation. Key Facts: Prevention. “Youth Risk Behavior Surveillance Race, Ethnicity & Medical Care. Washington, D.C.: -- United States, 2007.” Morbidity and Mortality The Henry J. Kaiser Family Foundation, 2007. Weekly Report 57, no. SS-4 (2008): 1-136. 431 Ibid. 415 U.S. Department of Health and Human Services, 432 Neal, D., G. Magwood, C. Jenkins, and C.L. Health Resources and Services Administration, Hossler. “Racial Disparity in the Diagnosis of Maternal and Child Health Bureau. National Survey Obesity among People with Diabetes.” Journal of Children’s Health 2003. Rockville, MD: U.S. of Health Care for the Poor and Underserved 17, Department of Health and Human Services, 2005. no. 2 Suppl (2006); 106-115. 416 American Obesity Association. “Obesity in 433 Levy, B.T. and P.S. Williamson. “Patient Per- Minority Populations.” American Obesity ceptions and Weight Loss of Obese Adults.” The Association. http://obesity1.tempdomain Journal of Family Practice 27, no. 3 (1988): 285-290. name.com/subs/fastfacts/Obesity_Minority_Pop.s 434 Olden, K. and S.L. White. “Health-Related Dispar- html. (accessed June 6, 2008). ities: Influence of Environmental Factors.” Medical 417 American Diabetes Association. “Total Prevalence Clinics of North America 89, no. 4 (2005): 721-738. of Diabetes and Pre-Diabetes.” American Diabetes 435 Kumanyika, S.K., M.C. Whitt-Glover, T.L. Gary, et Association. https://www.diabetes.org/diabetes- al. “Expanding the Obesity Research Paradigm statistics/prevalence.jsp. (accessed June 9, 2008). to Reach African American Communities.” 418 Olden, K. and S.L. White. “Health-Related Dispar- Preventing Chronic Disease 4, no. 4 (2007). ities: Influence of Environmental Factors.” Medical http://www.cdc.gov/pcd/issues/2007/oct/07_0 Clinics of North America 89, no. 4 (2005): 721-738. 067.htm. (accessed June 6, 2008). 419 U.S. Centers for Disease Control and 436 Liu, J., K.J. Bennett, N. Harun, X. Zheng, J.C. Prevention. “Prevalence of Regular Physical Probst, and R.R. Pate. Overweight and Physical Activity Among Adults —- United States, 2001 Inactivity among Rural Children Aged 10-17: A and 2005.” Morbidity and Mortality Weekly Report National and State Portrait. Columbia, SC: South 56, no. 46 (2007): 1209-1212. Carolina Rural Health Research Center, 2007. 420 U.S. Centers for Disease Control and 437 Ibid. Prevention. “Youth Risk Behavior Surveillance 438 Tudor-Locke, C. J.J. Kronenfeld, S.S. Kim, M. -- United States, 2007.” Morbidity and Mortality Benin, and M. Kuby. “A Geographical Comparison Weekly Report 57, no. SS-4 (2008): 1-136. of Prevalence of Overweight School-aged Children: 421 U.S. Department of Health and Human Services, The National Survey of Children’s Health 2003.” Health Resources and Services Administration, Pediatrics 120, no. 4 (2007): e1043-1050. Maternal and Child Health Bureau. National Survey 439 Lutfiyya, M.N., M.S. Lipsky, J. Wisdom-Behounek, of Children’s Health 2003. Rockville, MD: U.S. and M. Inpanbutr-Martinkus. “Is Rural Residency Department of Health and Human Services, 2005. a Risk Factor for Overweight and Obesity for U.S. 422 Kumanyika, S.K., M.C. Whitt-Glover, T.L. Gary, et al. Children?” Obesity 15, no. 9 (2007):2348-2356. “Expanding the Obesity Research Paradigm to 440 U.S. Department of Agriculture, Economic Reach African American Communities.” Preventing Research Service. Rural Children at a Glance. Chronic Disease 4, no. 4 (2007). http://www.cdc.gov/ Washington, D.C.: USDA, 2005. Available at pcd/issues/2007/oct/07_0067.htm. (accessed www.ers.usda.gov/publications/EIB1/EIB1.pdf. June 6, 2008). 140 441 Save the Children. CHANGE for Children in 456 Ibid. Rural America. Washington, D.C.: Save the 457 Petry, N. M., D. Barry, R. H. Pietrzak, and J. A. Children, 2008. Available at Wagner. “Overweight and Obesity are Associated http://www.savethechildren.org/programs/us- with Psychiatric Disorders: Results from the literacy-and-nutrition/STC_USP- National Epidemiologic Survey on Alcohol and CHANGE_brochure-FINAL-5-27-08.pdf. Related Conditions.” Psychosomatic Medicine 70, 442 Morton, L.W., and T.C. Blanchard. Starved for no. 3 (2008): 288-297. Access: Life in Rural America’s Food Deserts. 458 Ibid. Columbia, MO: Rural Sociological Society, 2007. Available at http://www.ruralsociology.org/ 459 Strine, T. W., A. H. Mokdad, S. R. Dube, et al. pubs/RuralRealities/RuralRealities1-4.pdf. “The Association of Depression and Anxiety with Obesity and Unhealthy Behaviors among 443 Walker, J.N., J.M. Del Rosso, and A.K. Held. Community-Dwelling U.S. Adults.” General Nutrition and Physical Activity Assessment of Hospital Psychiatry 30, no. 2 (2008): 127-137. Children in Rural America. Westport, CT: Save the Children, 2005. 460 National Institutes of Health. “Stress, Obesity Link Found.” U.S. Department of Health and 444 Save the Children. CHANGE for Children in Human Services. http://www.nih.gov/news/ Rural America. Washington, D.C.: Save the research_matters/july2007/07092007stress.ht Children, 2008. Available at m. (accessed May 8, 2008). http://www.savethechildren.org/programs/us- literacy-and-nutrition/STC_USP- 461 Kuo, L., J. Kitlinska, J. Tilan, et al. CHANGE_brochure-FINAL-5-27-08.pdf. “Neuropeptide Y Acts Directly in the Periphery on Fat Tissue and Mediates Stress-Induced 445 Valeo, T. “Growing Old, Baby-Boomer Style.” Obesity and Metabolic Syndrome.” Nature CBS NEWS Online, January 10, 2006. Medicine 13, no. 7 (2007): 803-811. http://www.cbsnews.com/stories/2006/01/10 /health/webmd/printable1195879.shtml 462 Zukowska, Z. “New Science behind Obesity: (accessed May 13, 2008). How Stress Can Make You Fat.” Power Point Presentation. 446 Leveille, S.G., C.C. Wee, and L.I. Iezzoni. “Trends in Obesity and Arthritis among Baby Boomers and 463 Hudson, J., E. Hiripi, H. Pope, and R. Kessler. “The Their Predecessors, 1971-2002.” American Journal of Prevalence and Correlates of Eating Disorders in Public Health 95, no. 9 (2005): 1607-1613. the National Comorbidity Survey Replication.” Biological Psychiatry 61, no. 3 (2007): 348-358. 447 Valeo, T. “Growing Old, Baby-Boomer Style.” CBS NEWS Online, January 10, 2006. 464 American Psychiatric Association. Diagnostic http://www.cbsnews.com/stories/2006/01/10 and Statistical Manual of Mental Disorder, 4th ed. /health/webmd/printable1195879.shtml Washington, D.C. American Psychiatric (accessed May 13, 2008). Association, 2000. 448 Leveille, S.G., C.C. Wee, and L.I. Iezzoni. “Trends 465 Pull, C. “Binge Eating Disorder.” Current in Obesity and Arthritis among Baby Boomers and Opinion in Psychiatry 17, no. 1 (2004): 43-48. Their Predecessors, 1971-2002.” American Journal of 466 Mayo Clinic.com. “Binge-eating disorder.” Mayo Public Health 95, no. 9 (2005): 1607-1613. Clinic.com. 449 Centers for Medicaid and Medicare Services. http://www.mayoclinic.com/health/binge-eating- National Health Expenditure Projections 2007-2017. disorder/DS00608. (accessed May 30, 2008). Washington, D.C.: U.S. Department of Health and 467 World Health Organization (WHO). “Obesity Human Services, 2007. http://www.cms.hhs.gov/ and Overweight.” WHO. http://www.who.int/ NationalHealthExpendData/Downloads/proj200 mediacentre/factsheets/fs311/en/index.html 7.pdf (accessed May 13, 2008). (accessed May 19, 2008). 450 Kuczmarski, R.J., K.M. Flegal, S.M. Campbell, and 468 Ibid. C.L Johnson. “Increasing Prevalence of Over- 469 World Health Organization (WHO). “Global weight among U.S. Adults.” Journal of the American Strategy: Overall Goal.” WHO. Medical Association 272, no. 3 (1994): 205-211. http://www.who.int/dietphysicalactivity/goals/en 451 Daviglus, M.L., K. Liu, L.L Yan, et al. “Relation /index.html (accessed May 19, 2008). of Body Mass Index in Young Adulthood and 470 World Health Organization (WHO). “Global Middle Age to Medicare Expenditures in Older Strategy on Diet, Physical Activity and Health: Age.” Journal of the American Medical Association Member State Documents.” WHO. 292, no. 22 (2004): 2743-2749. http://www.who.int/infobase/dpas/dpas.aspx 452 National Institute on Aging, National Institutes of (accessed April 8, 2008). Health, and U.S. Department of Health and 471 Cross Government Obesity Unit, Department Human Services. Growing Older in America: The of Health and Department of Children, Health and Retirement Study. Washington, D.C. U.S. Schools and Families. Healthy Weight, Healthy Department of Health and Human Services, 2007. Lives: A Cross-Government Strategy for England. http://hrsonline.isr.umich.edu/docs/databook/ London, England: H.M. Government, 2008. HRS_Text_WEB.pdf (accessed May 13, 2008). 472 BBC News. “Q&A: Anti-Obesity Strategy.” 453 Rotstein, G. “Boomer Health Decline Reported: BBC. January 23, 2008. Are They Less Well Than Earlier Group? Or is it 473 Cross Government Obesity Unit, Department Imagined?” Pittsburgh Post Gazette, March 18, 2007. of Health and Department of Children, 454 Rauscher, M. “Depression, Anxiety Tied to Schools and Families. Healthy Weight, Healthy Unhealthy Habits.” Reuters, March 5, 2008. Lives: A Cross-Government Strategy for England. 455 Ibid. London, England: H.M. Government, 2008. 141 474 Comments by Tim Lobstein, International 490 U.S. Department of Agriculture, Food and Obesity Taskforce, International Association for Nutrition Services. WIC The Special Supplemental the Study of Obesity, participant in the panel Nutrition Program for Women, Infants and Children. “Changing the Food Environment,” part of the Washington, D.C.: U.S. Department of Transatlantic Public Policy Approaches to Agriculture, 2006. http://www.fns.usda.gov/ Tackling Obesity and Diet-Related Disease confer- wic/WIC-Fact-Sheet.pdf (accessed June 3, 2008). ence held in Washington, D.C. on April 8, 2008. 491 Committee to Review the WIC Food Packages, 475 Foresight. Tackling Obesities: Future Choices - Food and Nutrition Board. WIC Food Packages: Summary of Key Messages. London, England: Time for a Change. Washington, D.C.: National Government Science Office, October 2007. Academies Press, 2005. http://www.foresight.gov.uk/Obesity/obesity_f 492 U.S. Department of Agriculture, Food and inal/20.pdf (accessed May 19, 2008). Nutrition Service. “WIC Program 476 Comments by Dr. Will Cavendish, Director of Participation and Costs.” U.S. Department of Health and Well-Being, United Kingdom Agriculture. http://www.fns.usda.gov/pd/ Department of Health, participant in the panel wisummary.htm (accessed April 30, 2008). “Changing the Food Environment,” part of the 493 U.S. Department of Agriculture, Food and Transatlantic Public Policy Approaches to Nutrition Service. “WIC Farmers’ Market Tackling Obesity and Diet-Related Disease confer- Nutrition Program.” U.S. Department of ence held in Washington, D.C. on April 8, 2008. Agriculture. http://www.fns.usda.gov/wic/FMNP 477 Cross Government Obesity Unit, Department /FMNPfaqs.htm (accessed April 30, 2008). of Health and Department of Children, 494 Ibid. Schools and Families. Healthy Weight, Healthy Lives: A Cross-Government Strategy for England. 495 U.S. Department of Agriculture, Food and London, England: H.M. Government, 2008. Nutrition Service. Senior Farmers’ Market Nutrition Program. Washington, D.C.: U.S. 478 Comments by Dr. Michel Chauliac, Coordinator, Department of Agriculture, 2007. National Nutrition and Health Program, French Ministry of Health, participant in the panel 496 Ibid. “Changing the Food Environment,” part of the 497 U.S. Department of Agriculture, Food and Transatlantic Public Policy Approaches to Nutrition Service. “Commodity Supplemental Tackling Obesity and Diet-Related Disease confer- Food Program.” U.S. Department of ence held in Washington, D.C. on April 8, 2008. Agriculture. http://www.fns.usda.gov/fdd/ 479 Reuters. “Child Obesity Rates Level Off in France.” programs/csfp/about-csfp.htm (accessed International Herald Tribune, May 15, 2008. April 30, 2008). 480 StataCorp. Stata Statistical Software: Release 9. 498 U.S. Department of Agriculture, Food and College Station, TX: StataCorp LP, 2005. Nutrition Service. Commodity Supplemental Food Program Fact Sheet. Washington, D.C.: U.S. 481 The high blood pressure question is part of a Department of Agriculture, April 2008. rotating core of questions which is asked in http://www.fns.usda.gov/fdd/programs/csfp/ alternating years by all states: in this case 2001, pfs-csfp.pdf (accessed April 30, 2008). 2003, 2005 etc. 499 Ibid. 482 One can think about this as an upper and lower bound on the true estimate because it is reason- 500 U.S. Department of Agriculture. “Center for able to think that some borderline hypertensives Nutrition Policy and Promotion.” U.S. Depart- would have answered “yes” in previous years ment of Agriculture. http://www.usda.gov/ while others would have answered “no”. cnpp/. (accessed June 3, 2008). 483 For hypertension the 3-year averages were calcu- 501 TRICARE. “Healthy Choices Initiatives Inside lated over 2001/2003/2005 and 2003/2005/2007. DoD.” TRICARE.mil. http://www.tricare.mil/ healthychoices/init.cfm (accessed June 4, 2008). 484 In all cases, observations with missing values accounted for less than 5 percent of the total 502 Department of Defense Education Activity. number of observations. “About DEA.” U.S. Department of Defense. http://www.dodea.edu/home/about.cfm 485 Food and Nutrition Service, U.S. Department (accessed May 1, 2008). of Agriculture. “About FNS.” USDA. http://www.fns.usda.gov/fns/about.htm 503 Federal Trade Commission. “FTC, HHS Release (accessed May 1, 2008). Report on Food Marketing and Childhood Obesity: Recommends Actions by Food 486 U.S. Department of Agriculture, Food and Companies and the Media.” News Release, May Nutrition Service. National School Lunch Program. 2, 2006. http://www.ftc.gov/opa/2006/05/ Washington, D.C.: U.S. Department of childhoodobesity.shtm (accessed April 30, 2008). Agriculture, July 2007. http://www.fns.usda.gov/ cnd/Lunch/AboutLunch/NSLPFactSheet.pdf 504 Administration on Aging. “You Can.” U.S. (accessed April 30, 2008). Department of Health and Human Services. http://www.aoa.gov/youcan/ (accessed April 487 Ibid. 29, 2008). 488 Ibid. 505 U.S. Centers for Disease Control and Prevention. 489 U.S. Department of Agriculture, Food and “The Preventive Health and Health Services Nutrition Service. “Child and Adult Care Food Block Grant.” U.S. Department of Health and Program.” USDA. http://www.fns.usda.gov/ Human Services. http://www.cdc.gov/nccdphp/ cnd/care/CACFP/aboutcacfp.htm (accessed blockgrant/ (accessed April 29, 2008). April 30, 2008). 142 506 U.S. Centers for Disease Control and Prevention 519 United States Department of the Interior, (CDC). Steps to a HealthierUS Program: Preventing Bureau of Land Management. “Take It Outside: Chronic Diseases Through Local Community Action. Children and Nature Initiative” Program Atlanta, GA: CDC, 2007. Announcement and Incentive Funding, Project 507 U.S. Centers for Disease Control and Prevention, Criteria and Application Process Information, National Center for Health Statistics. “About Information Bulletin No. 2008-045. Washington, NCHS.” U.S. Department of Health and Human D.C.: U.S. Department of the Interior, 2008. Services. http://www.cdc.gov/nchs/about.htm 520 U.S. Department of the Interior, National Park (accessed April 29, 2008). Service. “Improve your Life: Be Fit, Have Fun, Get 508 Institute of Medicine. Progress in Preventing Child- Healthy in Your National Parks.” Press Release, hood Obesity: How Do We Measure Up? Washington, June 12, 2006. http://home.nps.gov/applica D.C.: The National Academies Press, 2007. tions/digest/headline.cfm?type=PressReleases&id =659&urlarea=npsnews (accessed April 30, 2008). 509 U.S. Centers for Disease Control and Prevention. “Healthier Worksite Initiative - About Us.” U.S. 521 U.S. Department of the Interior, National Park Department of Health and Human Services. Service. Land and Water Conservation Fund State http://www.cdc.gov/nccdphp/dnpa/hwi/about_ Assistance Program 2007 Annual Report. Washington, us/index.htm. (accessed June 26, 2008.) D.C.: U.S. Department of the Interior, 2007. 510 U.S. Food and Drug Administration. Calories 522 U.S. Department of the Interior, National Park Count: Report of the Working Group on Obesity. Service. “Current Funding for Grants.” U.S. Washington, D.C.: U.S. Department of Health Department of the Interior. and Human Services, March 2004. http://www.nps.gov/ncrc/programs/lwcf/fundi http://www.cfsan.fda.gov/~dms/owg-toc.html ng.html (accessed May 28, 2008). (accessed May 1, 2008). 523 U.S. Department of the Interior, National Park 511 U.S. Food and Drug Administration, Center Service. “Pathways to Healthy Living: Health for Food Safety and Applied Nutrition. “Spot Projects.” U.S. Department of the Interior. the Block - Campaign at a Glance.” U.S. http://www.nps.gov/ncrc/portals/health/heal Department of Health and Human Services. thprojects.htm (accessed April 30, 2008). http://www.cfsan.fda.gov/~dms/spotcaag.html 524 Ibid. (accessed April 29, 2008). 525 Frank, L. D., M. A. Andresen, and T. L. Schmid. 512 U.S. Department of Health and Human “Obesity Relationships with Community Design, Services. U.S. Department of Health and Human Physical Activity, and Time Spent in Cars.” Services Budget in Brief Fiscal Year 2009. American Journal of Preventive Medicine 27, no. 2 Washington, D.C.: U.S. Department of Health (2004): 87-96. and Human Services, 2008. 526 U.S. Department of Transportation. “Mission http://www.hhs.gov/budget/09budget/2009B and History.” U.S. Department of udgetInBrief.pdf (accessed May 29, 2008). Transportation. http://www.dot.gov/ 513 Indian Health Service. “Health Promotion mission.htm (accessed April 30, 2008). and Disease Prevention - Welcome.” U.S. 527 U.S. Department of Transportation, Federal Department of Health and Human Services. Highway Administration. “Transportation http://www.ihs.gov/NonMedicalPrograms/HP Enhancement Activities.” U.S. Department of DP/index.cfm (accessed June 27, 2008). Transportation. http://www.fhwa.dot.gov/ 514 U.S. Department of Health and Human environment/te/ (accessed April 30, 2008). Services (DHHS). Fiscal Year 2009 -- Indian 528 Federal Highway Administration. “Bicycle and Health Service Justification of Estimates for Pedestrian Provisions in (SAFETEA-LU) Not Appropriations Committees. Washington, D.C.: Codified in Title 23.” U.S. Department of DHHS, 2008. Transportation. http://www.fhwa.dot.gov/ 515 National Institutes of Health. “Strategic Plan environment/bikeped/legtealu.htm (accessed for NIH Obesity Research.” U.S. Department May 8, 2008). of Health and Human Services. 529 Federal Highway Administration. “Fact Sheets http://obesityresearch.nih.gov/about/ on Highway Provisions.” U.S. Department of strategic-plan.htm (accessed April 29, 2008). Transportation. http://www.fhwa.dot.gov/ 516 Office of the Surgeon General. “About the safetealu/factsheets/nonmotorized.htm Office of the Surgeon General.” U.S. (accessed May 8, 2008). Department of Health and Human Services. 530 Posey, C.L. “Deduction or Distraction? The U.S. http://www.surgeongeneral.gov/aboutoffice.ht Treasury’s Stance on Obesity.” The CPA Journal, ml#dutiessg. (accessed May 1, 2008). July 2003. 517 U.S. Department of Health and Human 531 U.S. Department of Veterans Affairs. “MOVE! Services, Office of the Surgeon General. Weight Management Program.” U.S. Department “Childhood Obesity Prevention.” U.S. of Veterans Affairs. (accessed June 3, 2008). Department of Health and Human Services. http://www.surgeongeneral.gov/obesitypreven 532 U.S. Department of Veterans Affairs. tion.html (accessed April 29, 2008). “HealthierUS Veterans: A Prescription for Health.” U.S. Department of Veterans Affairs. 518 U.S. Department of Health and Human http://www.healthierusveterans.va.gov/Prescri Services, Office of Women’s Health. “WOMAN ptionForHealth.asp (accessed May 1, 2008). Challenge: Woman and Girls Out Moving Across the Nation.” U.S. Department of Health and Human Services. http://www.4woman.gov/ woman/index.cfm (accessed April 30, 2008). 143 1730 M Street, NW, Suite 900 Washington, DC 20036 (t) 202-223-9870 (f) 202-223-9871