The State ISSUE REPORT of Obesity: Better Policies for a Healthier America 2018 SEPTEMBER 2018 Acknowledgements Trust for America’s Health (TFAH) is a non-profit, non-partisan organization that promotes optimal health for every person and community and makes the prevention of illness and injury a national priority. For more information, visit www.tfah.org. For more than 45 years the Robert Wood Johnson Foundation has worked to improve health and health care. The Foundation works alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. TFAH would like to thank RWJF for their generous support of this report. TFAH BOARD OF DIRECTORS Gail Christopher, DN Stephanie Mayfield Gibson, MD John Rich, MD, MPH Chair of the Board, TFAH Senior Physician Adviser and Population Health Co-Director, President and Founder, Consultant Drexel University Center for Nonviolence and Ntianu Center for Healing and Nature Social Justice Cynthia Harris, PhD, DABT Former Senior Advisor and Vice President, Professor and Health Management and Policy Chair, Director and Professor, W.K. Kellogg Foundation Drexel University School of Public Health Florida A&M University Institute of Public Health David Fleming, MD Eduardo Sanchez, MD, MPH David Lakey, MD Vice Chair of the Board, TFAH Chief Medical Officer for Prevention and Chief of Chief Medical Officer and Vice Chancellor for Vice President of Global Health Programs, PATH the Center for Health Metrics & Evaluation, Health Affairs, American Heart Association Robert Harris, MD The University of Texas System Treasurer of the Board, TFAH Umair Shah, MD, MPH Octavio Martinez, Jr., MD, MPH, MBA, FAPA Senior Medical Director, Executive Director, Executive Director, General Dynamics Information Technology Harris County Public Health The University of Texas at Austin Hogg Theodore Spencer Foundation for Mental Health Vince Ventimiglia, JD Secretary of the Board, TFAH Chairman, Board of Managers, Karen Remley, MD, MBA, MPH, FAAP Senior Advocate, Climate Center, Leavitt Partners Former CEO/Executive Vice President, Natural Resources Defense Council The American Academy of Pediatrics AUTHORS Molly Warren, SM Sarah Ketchen Lipson, EdM, PhD James Krieger, MD, MPH Senior Health Policy Researcher and Analyst, Assistant Professor, Executive Director, Healthy Food America Trust for America’s Health Boston University School of Public Health Clinical Professor of Medicine and Health Services, Associate Director, Healthy Minds Network University of Washington School of Public Health Stacy Beck, JD Consultant Megan Wolfe, JD Corby Kummer Policy Development Manager, Editor-in-Chief, Ideas Magazine, Jack Rayburn, MPH Trust for America’s Health The Aspen Institute Senior Government Relations Manager, Senior Lecturer, Trust for America’s Health REPORT PEER REVIEWERS Tufts University Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy CONTRIBUTORS William Dietz, MD, PhD Chair of Sumner M. Redstone Global Center for Marion Nestle, PhD, MPH John Auerbach Prevention and Wellness, Professor of Nutrition, Food Studies, and Public President and CEO, The George Washington University Milken Health, Emerita, New York University Trust for America’s Health Institute School of Public Health Loel Solomon, MPP, PhD Anne De Biasi, MHA Shiriki Kumanyika, PhD, MPH Vice President of Community Health, Director of Policy Development, Professor Emerita of Epidemiology, Kaiser Permanente Trust for America’s Health University of Pennsylvania Research Professor in Community Health & Kendall Stagg, MA, JD Vinu Ilakkuvan, MSPH, DrPH Prevention, Director of Program Management, Consultant Drexel University Dornsife School of Public Health Community Health, Kaiser Permanente 2 TFAH • RWJF The State of TABLE OF CONTENTS Table of Contents INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . 4 ii. Elementary and Secondary Education . 38 Obesity Local School Wellness Policies . . . . . . 38 SECTION 1: Recommendations . . . . . . . . . . .7 Smart Snacks in Schools . . . . . . . . . . 38 CDC School Initiatives . . . . . . . . . . . . . 38 SECTION 2: Causes and Consequences of School-Based Physical Activity and Obesity . . . . . . . . . . . . . . . . . . 12 Physical Education Programs . . . . . . . . 39 SECTION 3: Obesity-Related Data and Trends 15 D. Community Policies and Programs . . . . . 40 i. Community Design and Land Use . . . . . 40 A. Trends in Adult Obesity . . . . . . . . . . . . . 15 ii. Safe Routes to School . . . . . . . . . . . . 41 i. Demographic Analysis . . . . . . . . . . . . . 16 iii. CDC Community Initiatives . . . . . . . . . 42 ii. State Analysis . . . . . . . . . . . . . . . . . . 19 E. Fiscal Policies to Promote Nutrition . . . . 45 B. Trends in Childhood Obesity . . . . . . . . . . 23 i. Healthy Food Financing Initiative . . . . . . 45 i. National Childhood Obesity Rates . . . . . 24 ii. New Markets Tax Credit . . . . . . . . . . . .46 ii. Early Childhood Obesity Rates . . . . . . . 25 iii. Beverage Taxes . . . . . . . . . . . . . . . . . 46 iii. Obesity Rates in Children Ages 10 to 17 . . 25 iv. High School Obesity Rates . . . . . . . . . 26 F. Obesity Prevention in the Military . . . . . . 48 i. Military Initiatives . . . . . . . . . . . . . . . . 48 SECTION 4: Obesity-Related Programs and Policies . . . . . . . . . . . . . . . . . . 27 G. Healthcare Coverage and Programs . . . . 49 i. Medicare and Medicaid . . . . . . . . . . . . 49 A. Nutrition Assistance . . . . . . . . . . . . . . . 27 ii. Healthcare Systems and Hospital i. Women, Infants, and Children Program . 28 Programs . . . . . . . . . . . . . . . . . . . . . . 50 ii. Child Nutrition Programs . . . . . . . . . . . 29 Screening Services and Clinical Decision iii. Supplemental Nutrition Assistance Support . . . . . . . . . . . . . . . . . . . . . . . 50 Program . . . . . . . . . . . . . . . . . . . . . . 31 Provider Competencies for the Prevention iv. Food Insecurity Nutrition Incentive and Management of Obesity . . . . . . . . . . 50 Program . . . . . . . . . . . . . . . . . . . . . . 32 Community Benefit Programs . . . . . . . . 50 Healthy Food Procurement . . . . . . . . . . 51 B. Nutrition Information and Education . . . . 32 Breastfeeding Support . . . . . . . . . . . . 51 i. Dietary Guidelines . . . . . . . . . . . . . . . . 32 ii. Nutrition Labels . . . . . . . . . . . . . . . . . 33 APPENDIX: Obesity-Related Policies iii. Menu Labeling . . . . . . . . . . . . . . . . . . 34 Implemented by States . . . . . . . . . . . . . . . 52 vi. Food and Beverage Marketing . . . . . . . 35 C. Child Care and Education Requirements . 36 REFERENCES . . . . . . . . . . . . . . . . . . . . . . 56 i. Early Child Care and Education . . . . . . . 36 Head Start . . . . . . . . . . . . . . . . . . . . . 36 States’ Early Child Care and Education Requirements . . . . . . . . . . . . . . . . . . . 37 CDC ECE Initiatives . . . . . . . . . . . . . . . 37 This report can be viewed online at tfah.org/stateofobesity2018. For more data on obesity prevalence, policies and programs, visit stateofobesity.org. SEPTEMBER 2018 I NT RO D UC TION The State of INTRODUCTIION Introduction Obesity Each year, the State of Obesity: Better Policies for a Healthier America report highlights the latest obesity trends as well as strategies, policies, programs, and practices that can reverse the epidemic. State of Obesity also demonstrates the level of commitment necessary to effectively fight obesity on a large scale and includes key recommendations for specific action. New studies documenting national According to the most recent National obesity rates and trends from the past Health and Nutrition Examination year reinforce what we already know: Survey (NHANES), 18.5 percent of obesity rates are alarmingly high; children and 39.6 percent of adults sustained, meaningful reductions had obesity in 2015–2016. These are have not yet been achieved nationally the highest rates ever documented by except possibly among our youngest NHANES.1 There were no statistically children in low-income families; significant changes in youth or adult many populations continue to see rates compared with the 2013–2014 steady increases in obesity; and racial, survey, but rates have increased ethnic, and geographic disparities are significantly since 1999–2000, when persistent. Therefore, addressing the 13.9 percent of children and 30.5 obesity epidemic remains imperative for percent of adults had obesity.2 ensuring the health of the nation. National Obesity Rates for Adults (Age-Adjusted) and Children 50 40 39.6% 30 30.5% 20 18.5% 10 13.9% SEPTEMBER 2018 0 1999-2000 2015-2016 1999-2000 2015-2016 Children (Age 2-19) Adults (Age 20+) Source: NHANES The severity of racial, ethnic, and in 2017.3 That survey also reported geographic disparities remains striking. persistent inequities–18.2 percent of Black and Latino children and adults Black and Latino high schoolers had continue to have higher obesity rates obesity compared with 12.5 percent of than Whites and Asians. The Youth Risk their White peers. Two other studies Behavior Survey, which is based on self- found that adults and children who reported data, found that 14.8 percent live in rural areas have higher rates of of U.S. high school students had obesity severe obesity.4,5 While obesity rates can seem intractable, can be successful at reducing the weight there have been some promising of children in low-income communities developments among age- and who are overweight or have obesity—but geographic-specific populations. Rates of that long-term, continued support is obesity and severe obesity have declined needed or improvement can be lost.9,10 among 2- to 4-year-olds enrolled in the Second, the Healthy Communities Study, Special Supplemental Nutrition Program which included more than 5,000 children for Women, Infants, and Children (WIC). in 1,000 communities, found that From 2010 to 2014, the rate dropped from children living in localities that did more 15.9 percent to 14.5 percent nationally. to encourage physical activity and healthy The drop was geographically widespread: nutrition had lower body mass index 31 states and three U.S. territories and waist circumference measures.11 And reported declines.6,7 Some communities third, a recent study found that states also have documented declines in overall implementing CDC-funded nutrition childhood obesity rates.8 and physical activity programs between 2000 and 2010 had 2.4 percent to 3.8 And, in the past year, more evidence and percent reduction in the odds of obesity lessons emerged from research of policies among adults.12 Together, these studies and programs focused on addressing demonstrate that states and communities obesity at the individual, community, and that support multi-sector collaborations state levels. First, the U.S. Centers for and innovative policy approaches Disease Control and Prevention (CDC) over sustained periods can achieve shared encouraging research about a reductions in obesity and offer models for project in Texas that found an intensive, nationwide adoption. multi-sector program with a clinical focus TFAH • RWJF 5 In addition, our analysis of new data from the 2017 Behavioral Risk Factor Adult Obesity Rates by State, 2017 Surveillance System (BRFSS) survey shows substantial variation in adult WA MT ME obesity rates across the country. The ND OR MN VT South (32.4 percent) and Midwest (32.3 ID NH SD WI NY MA percent) had higher obesity rates than WY MI CT RI the Northeast (27.7 percent) and West NE IA PA NJ NV OH DE (26.1 percent). Differences were even CA UT IL IN MD CO WV DC more pronounced between some states. KS MO VA KY For example, adult obesity rates in West NC AZ TN Virginia, where 38.1 percent of residents NM OK AR SC had obesity, were nearly 70 percent MS AL GA higher than those in Colorado, where TX LA 22.6 percent of residents had obesity.13 <25% FL 25% – <30% AK Accelerating progress to address 30% – < 35% obesity will require collaboration, 35%+ HI sufficient resources, and sustained efforts, including by federal, state, and SOURCE: BRFSS local agencies and the private sector. For decades, experts at CDC, National Institutes of Health (NIH), U.S. Department of Agriculture (USDA), nutrition standards for school breakfast Limiting policies and funding for obesity- U.S. Department of Education, the and lunch programs that went into prevention efforts at a moment when the Administration for Children and effect in 2012. The question is whether enormity and intractability of this public Families, and the Food and Drug schools will continue the healthy health problem is so pressing will have Administration (FDA) have been changes that they already implemented. adverse consequences for the country researching and developing strategies In 23 states, 100 percent of school and its residents. After all, Americans’ to prevent and address obesity. Over food agencies were compliant as of health is directly tied to national security the past 15 years, policymakers have September 2016 and at least 90 percent and the U.S. economy.17,18 taken significant steps to implement of agencies were compliant in every new approaches through the WIC In response to ongoing high levels state.14,15 FDA requirements for food program, the Supplemental Nutrition of obesity, the United States must retailers and restaurants to post calorie Assistance Program, the National be bold enough to find and test new information on menus and elsewhere School Lunch and Breakfast Programs, strategies, and resolute enough to went into effect in May 2018, more updated menu labeling rules, and an intensify evidence-based solutions that than eight years after becoming law updated Nutrition Facts label. Some of are already making a difference. This and after several unnecessary delays.16 these efforts were delayed or weakened, means communities, governments, Recent federal budget proposals include preventing full implementation and and other institutions need to work deep cuts to key health programs thus denying researchers the ability to across sectors and levels to support such as the CDC’s National Center for effectively study which efforts best help policies, practices, and programs that Chronic Disease Prevention and Health people maintain a healthy weight. work. Over time, these investments can Promotion. This cut would eliminate pay off—in lives saved and in reduced For instance, a USDA rule published dedicated funding for addressing healthcare costs. in November 2017 scaled back key nutrition, physical activity, and obesity. 6 TFAH • RWJF SECTI O N 1 The State of SECTION 1: RECOMMENDATIONS Recommendations Obesity The annual State of Obesity reports have documented how, over the past 15 years, a series of evidenced-based policies and programs have helped Americans eat healthier and provided more opportunities for physical activity in their homes, schools, and communities. These initiatives have taken root at the local, state, and federal levels, with participation from the private sector. The impact has been substantial: l I n 2017, new rules strengthened school wellness policies to ensure l M ore than 30 million children eat healthier food marketing in schools, healthier school breakfasts, lunches, and and updated nutrition standards snacks thanks to the updated nutrition for the more than four million standards ushered in by the Healthy, children who participate in programs Hunger-Free Kids Act of 2010.19 associated with the Child and Adult l M ajor food and beverage companies Care Food Program.23,24 removed 6.4 trillion calories from the l I n 2018, menu labeling provisions of marketplace between 2007 and 2012.20 the Affordable Care Act took effect, l T hirty-three states have implemented covering approximately 300,000 food Complete Streets policies to encourage retail establishments nationwide; FDA and facilitate walking and biking.21 estimates this will save approximately $8 billion in health costs over the l T hirty-five states have made Healthy next two decades.25,26 Food Financing Initiative investments to increase healthy food access in underserved communities.22 SEPTEMBER 2018 The menu labeling provisions of the Affordable Care Act will save approximately $8 billion in health costs over the next two decades according to an FDA analysis of these rules. A renewed commitment to obesity-prevention policies and programs, and continued innovation at the state and local levels is critical to achieving success among more children and adults in our country. But this progress is fragile, and at risk TFAH and RWJF recommend three of being halted or even reversed. This is guiding principles regarding obesity particularly troubling because sustained, prevention: meaningful reductions in obesity have 1. romote policies and scale programs P not yet been achieved nationally (except that take a multi-sector approach. possibly among our youngest children Multi-sector, aligned initiatives— in low-income families), and racial, collaborations that involve, for ethnic, and geographic disparities in example, health departments, schools, obesity rates persist. transportation departments, local A renewed commitment to obesity- businesses, and other agencies—are prevention policies and programs, more likely to achieve results. and continued innovation at the state 2. dopt and implement policies that A and local levels is critical to achieving help make healthy choices easy. success among more children and Federal, state, and local governments adults in our country. Effective can create conditions in schools, obesity prevention efforts also require communities, and workplaces that substantial investment to support multi- make healthy eating and active living faceted, multi-sector collaborations; accessible, affordable, and convenient. merging multiple sources of public and private funding can best ensure that 3. Invest in programs that level the these efforts are sustainable as a long- playing field for all individuals and term enterprise. This is particularly families. While obesity affects all important for populations that have populations, some have significantly elevated risk. higher levels than others—often due to social and economic factors largely beyond their control, such as racism, poverty, and lack of access to healthcare. Carefully designed initiatives, that are informed by community input and address these challenges, are critically important. Investing in these programs requires not only adequate funding, but also staffing, public promotion, and other community resources. 8 TFAH • RWJF TFAH and RWJF offer the following specific recommendations to federal policymakers, state and local policymakers, the food and restaurant sectors, and healthcare providers and systems. Federal Policymakers Congress and the Administration l C ontinue to implement the for Americans reflect the latest and l S upport and expand policies and Community Eligibility Provision that best nutrition science, including programs aimed at addressing obesity allows schools in high-poverty areas developing recommendations for at the federal, state, and community to serve free meals to all students, children ages 2 and under in a levels, including programs in CDC’s regardless of family income. transparent, timely manner. Division of Nutrition, Physical Activity l S upport and implement local school l A ctively support the recommendations and Obesity, community health wellness policy rules, including the of “Step It Up! The Surgeon General’s programs like the Racial and Ethnic provision that all foods and beverage Call to Action to Promote Walking and Approaches for Community Health advertisements on school campuses Walkable Communities.” program (REACH), and programs meet Smart Snacks nutrition guidelines. that focus on school health in CDC’s U.S. Department of Education Division of Population Health. l E xpand and evaluate pilots and l M aintain the Office of Safe and programs aimed at increasing Healthy Schools, as well as Title I l E nsure that every state public health consumption of fruits, vegetables, and and Title IV programs under the agency receives targeted support to other healthy foods under SNAP and Every Students Succeeds Act (ESSA), promote healthy eating and active other nutrition programs. through which schools can receive living. Maintain and increase obesity- l C ontinue to ensure that WIC provides funding for physical education and related emphasis in the Prevention mothers, infants, and young children physical activity initiatives. and Public Health Fund and support the Healthy Food Financing with access to affordable, healthy food l I ssue regular guidance covering Initiative in the Administration for and breastfeeding support. programs, such as early childhood Children and Families to ensure that U.S. Department of Health and programs, supported through ESSA underserved communities have access Human Services that encourage healthy eating, to grocery stores. opportunities for physical activity, l I n partnership with the U.S. limits on screen time, and other l M aintain and strengthen essential Department of Agriculture, ensure activities that promote health. nutrition supports for low-income that the 2020-2025 Dietary Guidelines children, families, and individuals through programs—like the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)—and expand programs and pilots to make healthy foods more available and affordable through the program. U.S. Department of Agriculture l M aintain nutrition standards for school meals that were in effect prior to USDA’s interim final rule from November 2017, as well as current nutrition standards for school snacks. TFAH • RWJF 9 U.S. Food and Drug Administration l S tates should support access for low- l E nsure no further delays to the income families to targeted home implementation of the updated visiting and community-based programs Nutrition Facts label, currently that provide families with resources and scheduled to begin in 2020, and connections to parenting education, encourage and provide guidance to nutrition programs, and other services. companies who wish to utilize the l S tates and localities should ensure the updated label prior to the deadline. availability of healthy food retailers in l E nsure full compliance with menu underserved communities. labeling rules covering chain restaurants l S tates and localities should and similar food retail establishments. implement evidence-based nutrition l E ncourage non-chain restaurants standards for foods and beverages to implement menu labeling rules offered in government food service voluntarily. and vending machines. l S tates and localities should ensure all State and Local Policymakers restaurant meals marketed to children l S tates should continue to meet or meet nutrition standards, and remove exceed federal nutrition standards for sugary drinks from all restaurant school meals and snacks. children’s meals. l E ducation agencies and school districts l S tates should support efforts to make should continue and expand flexible Safe Routes to School programs breakfast programs, such as second- universally available and secure state- chance breakfasts, breakfast on-the-go, level appropriations or Transportation and breakfasts in classrooms. Alternatives Program allocations for infrastructure and other projects. l S tates should ensure that all students receive at least 60 minutes of physical l A t the state and local level, require education or activity during each that all road construction and school day. reconstruction projects adopt a Complete Streets approach, ensuring l E ducation agencies and school that transportation plans are safe and districts should continue to support convenient for all users. local wellness plan implementation to ensure students have healthy learning l S tates should incentivize employers and environments conducive to improved businesses to expand effective employee school performance. wellness programs to promote healthy eating and physical activity. l S tate ESSA plans should encourage schools and partners in healthcare l S tates should encourage innovation by and public health to address implementing and testing pilot policies childhood obesity. that show promise. l S tates should follow expert guidance l S tates should refrain from adopting and adopt and implement best practices preemption policies that limit the for nutrition, activity, and screen time ability of local communities to improve regulations covering child care and day the health of their residents. care settings, including by investing in Quality Improvement Ratings Systems. 10 TFAH • RWJF Food and Restaurant Sectors l F ood and beverage companies should follow the American Heart Association’s guidance concerning children’s intake of added sugars as they develop, reformulate, and market foods and beverages intended for children, and adopt the updated Nutrition Facts label on all products as quickly as possible. l F ood and beverage companies should eliminate children’s exposure to advertising and marketing of unhealthy products. l R estaurants should remove sugary drinks from all children’s meals, and ensure the meals they market to children meet minimum nutrition standards. l R estaurants should incorporate more fruits and vegetables into menus and make healthy beverages and sides the default option. l N on-chain restaurants should voluntarily abide by the FDA’s new counseling as a covered benefit, and menu labeling rules. evaluate its use and effectiveness. Health plans, medical schools, Healthcare System continuing medical education, and and Providers public health departments should l H ospitals should no longer sell raise awareness about the need and or serve sugary drinks on their availability of these services. campuses; they should also improve l T he healthcare system should extend the nutritional quality of meals and programs that are effective in terms promote breastfeeding. of costs and performance, such as l N onprofit hospitals should prioritize the Diabetes Prevention Program childhood obesity prevention (DPP) and the community health programs as they work to meet their worker–clinical coordination models. community benefit requirements. Providers and payers should allocate resources to educating and referring l A ll public and private health plans patients to DPP and other covered should cover the full range of benefits as appropriate. obesity-prevention, treatment, and management services, including l P ublic and private payers should cover nutritional counseling, medications, value-based purchasing models that and behavioral health consultation. incorporate health outcome measures that incentivize clinicians to prioritize l M edicare should encourage eligible healthy weight. beneficiaries to enroll in obesity TFAH • RWJF 11 S EC T I ON 2 : The State of SECTION 2: CAUSES AND CONSEQUENCES OF OBESITY Causes and Consequences Obesity of Obesity Obesity is a harmful, costly, and complex health problem. The underlying causes of obesity are foods and beverages. As a consequence, complex and interconnected, ranging many Americans eat too few fruits and from economic and policy dynamics to vegetables and consume too many environmental influences, social norms, calories in the form of highly processed and individual and family factors.27 foods, and fewer than half meet national Individuals are key to ensuring that they guidelines for physical activity.28,29,30,31 and their families are living a healthy Low-income communities, rural lifestyle, but the places people live, areas and communities of color learn, work and play have major impacts are disproportionately affected by on the choices available to them. For obesity.32,33,34,35 For example, according example, high-calorie foods are less to NHANES 2015-2016, obesity rates expensive and more available in some among Latino and Black Americans neighborhoods; many communities are 20 percent higher than among lack safe, accessible places to walk, bike, Whites. Not coincidentally, Black and play; and children and adults are communities have more fast-food inundated by advertising for unhealthy SEPTEMBER 2018 establishments and fewer grocery stories in children between 2001 and 2012 than White communities.36,37 Similarly, found a 7.1 percent annual increase Societal Costs of Obesity low-income communities are far less in type 2 cases diagnosed per 100,000 $149 billion likely to have healthy food, parks, and children ages 10 to 19. Over the same in medical expenses per year green spaces available to them and period, type 1 diabetes diagnoses are four and a half times less likely increased by 1.4 percent annually to have recreational facilities such as for children ages 0 to 19.56 Research $66 billion in lower productivity pools, tracks, tennis courts, and sports also shows that children with obesity fields.38,39,40 Researchers have also found perform worse in school and have 1 in 3 young that food and beverage companies higher risk of bullying and depression.57 adults ineligible to serve in the military disproportionately target advertising for Ensuring that all kids have the many of their least nutritious brands, opportunity to grow up at a healthy including fast food, candy, sugary drinks, weight, including by having access to and snacks to Black and Latino youth.41 nutritious food and plenty of time for active play every day, would help more These factors intersect and contribute young people reach their full potential. to higher obesity rates, increasing the risk of a range of diseases and higher The obesity epidemic also poses several mortality.42,43,44 Specifically, obesity threats to our nation: obesity increases increases the risk of developing type healthcare costs, decreases on-the-job 2 diabetes, high blood pressure, heart productivity, and impacts our nation’s disease, stroke, arthritis, sleep apnea, military readiness. A 2016 study found liver disease, kidney disease, gallbladder that obesity costs the United States $149 disease, and certain types of cancer.45 In billion in medical expenses annually— parallel with obesity rates, a record high with about half of those expenses paid number of Americans—40 percent— by publicly financed Medicare and are living with diabetes or prediabetes Medicaid programs.58,59,60 Indirect, or Obesity increases the risk of according to CDC.46 That’s more than non-medical, costs from obesity also developing type 2 diabetes, high 100 million American adults. run into the billions of dollars due to missed time at school and work, lower blood pressure, heart disease, Obesity is also associated with mental productivity, premature mortality, and stroke, arthritis, sleep apnea, health conditions, including higher increased transportation costs.61 rates of depression. Weight bias and liver disease, kidney disease, stigma are pervasive and can heighten Being overweight or having obesity is gallbladder disease, and certain or even create mental health issues.47,48 the most common reason young adults Obesity also increases the chances of are ineligible for military service. In types of cancer pregnancy complications, including addition, the proportion of active-duty gestational diabetes, preeclampsia, service members who have obesity has cesarean delivery, and stillbirth.49,50,51 risen in the past decade—along with These health consequences translate to healthcare costs and lost work time.62 higher medical costs. One study found According to Mission: Readiness, a that individuals with obesity had medical nonpartisan group of more than 700 costs that were 42 percent higher than retired admirals and generals, excess healthy-weight individuals.52 weight prevents nearly one in three young adults from qualifying for military Children who have obesity are at greater service and the Department of Defense risk for certain diseases like type 2 is spending more than $1 billion each diabetes and high blood pressure.53,54,55 year on obesity-related issues.63,64 A 2017 study of new diabetes diagnoses TFAH • RWJF 13 America’s obesity problem developed where they live, how much money they over decades and likewise will require make, or what their racial or ethnic decades to fix. The nation needs a background is—achieve a healthy long-term, continuous commitment weight and live healthier, longer, and to policies and programs that will help more productive lives. all children and adults—no matter WHAT IS OBESITY? “Obesity” means that an individual’s body measure, although it has its limitations fat and body fat distribution exceed the and is not accurate for all individuals.67 level considered healthy.65,66 There are BMI is calculated by dividing a person’s many methods of measuring body fat. Body weight (in kilograms) by his or her height mass index (BMI) is an inexpensive method (in square meters). The BMI formula for that is often used as an approximate measurements in pounds and inches is: BMI = ( Weight in pounds (Height in inches) x (Height in inches) ) x 703 For adults, BMI is associated with the following weight classifications: BMI LEVELS FOR ADULTS AGES 20+ BMI Level Weight Classification Below 18.5 Underweight 18.5 to < 25 Healthy weight 25 to < 30 Overweight 30 and above Obesity 40 and above Obesity Class 3 or Severe Obesity Childhood obesity is measured differently. That’s because body fat levels change over the course of childhood and are different for boys and girls. Childhood weight classifications are determined by comparing a child’s height and weight with BMI-for-age growth charts developed by the CDC using data collected from 1963 to 1965 and from 1988 to 1994.68 BMI LEVELS FOR CHILDREN AGES 2-19 BMI Level Weight Classification Below 5th percentile Underweight 5th to < 85th percentile Healthy weight 85th to < 95th percentile Overweight 95th percentile and above Obesity 120 percent of 95th percentile and above Severe Obesity 14 TFAH • RWJF SECTI O N 3 The State of SECTION 3: OBESITY-RELATED DATA AND TRENDS Obesity-Related Data and Trends Obesity A. TRENDS IN ADULT OBESITY For decades, the national adult obesity rate, as measured by the National Health and Nutrition Examination Survey (NHANES), has been rising.69 The most recent data, from 2015–2016, show adult obesity rates now approaching 40 percent, after holding at around 34-35 percent between 2005 and 2012.70,71 While recent year-to-year changes have not been statistically significant, additional data will provide greater clarity on recent national trends. Percent of Adults with Obesity, 1988-2016 (Age-Adjusted) 50% 39.6% 40% 37.7% 34.3% 35.7% 34.9% 32.2% 33.7% 30.5% 30.5% 30% 22.9% 20% 10% 0% 1988-1994 1999-2000 2001-2002 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 Source: NHANES State and local data shows more nuance. to neighborhood. Nearly 800 of the Some communities are maintaining a nation’s 3,000 counties have a self- more stable rate and some are seeing reported adult obesity rate at or higher increases. Six states — Iowa, above 35 percent. Obesity rates range Massachusetts, Ohio, Oklahoma, Rhode from a high of 48 percent in Macon, Island, and South Carolina — had Alabama, to a low of 13 percent in statistically significant increases in Eagle, Colorado.72 their obesity rate between 2016 and The next sections present the most 2017, while the other 44 states and the recent data available on adult obesity District of Columbia had no statistically levels by demographics and geography, significant change in their obesity rates using the two primary U.S. surveys SEPTEMBER 2018 between 2016 and 2017. used to track adult obesity rates, Obesity rates also can differ from NHANES and Behavioral Risk Factor county to county and neighborhood Surveillance System (BRFSS). Obesity rates range from a high of 48 percent in Macon, Alabama, to a low of 13 percent in Eagle, Colorado. DATA SOURCES FOR ADULT OBESITY MEASURES 1. The National Health and Nutrition inhibit break out of state or local data, population of that state, and (3) the Examination Survey is the source for as well as break out by racial and survey is conducted annually, so national obesity data in this report. ethnic groups by age.73 new obesity data are available each As a survey, the NHANES has two year.74 The downsides of the survey 2. The Behavioral Risk Factor main advantages: (1) it examines a include using self-reported weight and Surveillance System is the source nationally representative sample of height, which results in lower reported for state-level adult obesity data in Americans ages 2 and older, and (2) obesity rates than actual rates due to this report. As a survey, BRFSS has it combines interviews with physical people’s tendency to underreport their three major advantages: (1) it is the examinations to ensure data accuracy. weight and exaggerate their height, largest ongoing telephone health The downsides of the survey include a and sample sizes that, in some small survey in the world (approximately time delay from collection to reporting states, prohibit meaningful data 400,000 interviews per year) (2) each and a small survey size (approximately about racial and ethnic groups. state survey is representative of the 5,000 interviews per two years) that i. DEMOGRAPHIC ANALYSIS Obesity levels vary substantially among demographic groups. Below are breakdowns of available demographic groups from the most recent NHANES data (2015–2016).75 Percent of Adults With Obesity by Demographic Group, 2015-2016 (Age-Adjusted) 50% 46.8% 47.0% 42.8% 39.6% 41.1% 41.0% 40% 37.9% 37.9% 35.7% 30% 20% 12.7% 10% 0% All Adults Men Women Ages 20-39 Ages 40-59 Ages 60+ Asians Blacks Latinos Whites Source: NHANES l Race/ethnicity: There are large • sian Americans have far lower A differences in obesity levels among rates of obesity than any other racial racial and ethnic groups: or ethnic group (12.7 percent). Notably, however, there is discussion • besity rates are much higher O that Asians should have a lower BMI among Latinos (47.0 percent) and cut-off for obesity than other race/ Blacks (46.8 percent) than among ethnicities since they have higher Whites (37.9 percent). health risks at a lower BMI.76 16 TFAH • RWJF Percent of Adults With Obesity by Race/Ethnicity and Sex, 2015-2016 (Age-Adjusted) 60% 54.8% 50% 50.6% 41.1% 43.1% 40% 38.0% 37.9% 37.9% 36.9% 30% 20% 14.8% 10% 10.1% 0% All Women Asian Black Latina White All Men Asian Men Black Men Latino Men White Men Women Women Women Women Source: NHANES l ex: Women have slightly higher levels S Black men have relatively similar of obesity and severe obesity compared obesity rates (43.1, 37.9, and 36.9 with men: percent, respectively). • n 2015–2016, 41.1 percent of I l ge: Obesity levels vary moderately A women had obesity versus 37.9 among Americans of different ages: percent of men. • Middle-age and older adults are more • omen are also more likely to have W likely to have obesity: 42.8 percent of severe obesity (9.7 percent of women 40- to 59-year-olds and 41.0 percent compared with 5.6 percent of men). of adults ages 60 and over have obesity, which is about 20 percent • acial/ethnic inequities are largely R higher than younger adults ages 20 to driven by the differential obesity 39 (35.7 percent have obesity). rates among women: more than half of Black and Latina women • Middle-age adults are more (54.8 percent and 50.6 percent, likely to have severe obesity (8.5 respectively) have obesity compared percent) followed by younger with 38.0 percent of White women. adults (7.8 percent) and older In contrast, Latino, White, and adults (6.3 percent). TFAH • RWJF 17 Additionally, other analyses and and those at 100 to 199 percent FPL— Percent of Adults with Obesity in Metro research show important variations in had higher obesity levels than those and Rural Areas, 2016 obesity rates by education, income level, with incomes at 400 percent FPL or and urban or rural population: more (29.7 percent).79 Note: these data are driven by rates among White women. l ducation: Individuals with lower E 28.7% 34.2% education levels are more likely to • his dynamic holds true for children, T have obesity. too. A CDC analysis of 2011-2014 NHANES data for children ages 2-19 Adults in Metro Areas Adults in Rural Areas • ccording to 2016 BRFSS data, 35.5 A found that 18.9 percent of kids in the percent of adults with less than a lowest income group (<130 percent high school education had obesity Percent of Adults with Obesity by FPL) had obesity, 19.9 percent of kids compared with 22.2 percent of Education Level, 2016 in the middle-income group (>130 college graduates—a difference of percent to <350 percent FPL) had more than 50 percent.77 obesity, and 10.9 percent of kids in 22.2% 35.5% • The difference is even greater the highest income group (>350% when looking at children and the percent FPL) had obesity.80 education level of the head of l ural/urban: Rural areas and counties R household. A CDC analysis of 2011- Adult College Adults with Less than have higher rates of obesity. Graduates a High School Education 2014 NHANES data found that, when looking at homes where the • ccording to 2016 BRFSS data, A head of household was a high school adult obesity rates were 19 percent Percent of Adults with Obesity by Income, 2011-2014 graduate or less, 21.6 percent of higher in rural regions than they children ages 2-19 had obesity, while were in metro areas. More than in homes with a head of household one-third (34.2 percent) of adults that graduated college, 9.6 percent of in rural areas had obesity compared 29.7% 42.6% children had obesity. That’s less than with 28.7 percent of metro adults. half the rate for kids with parents who This trend holds true at the state- attended college.78 level—except in Wyoming—as well. Adults with Incomes Adults with Incomes 400%+ FPL 100-400% FPL Rural areas also have higher levels of l ncome: Generally, the more someone I obesity-associated chronic diseases earns, the less likely they are to have (e.g., diabetes and heart disease).81 obesity. • ikewise, a CDC analysis of 2013-2016 L • ccording to a CDC analysis of 2011- A NHANES data found that adults (age 2014 NHANES data, there is one 20 and older) who live in the most exception to this trend: the very poor, urban areas of the country had the who live below the federal poverty lowest obesity rates. They also found line (FPL), had lower obesity rates that obesity rates increased between (39.2 percent in 2015) than those 2001-2004 and 2013-2016, across with incomes just above the poverty urban, suburban, or rural areas.82 line (42.6 percent). But, both income groups—those below the poverty line 18 TFAH • RWJF WHY ARE REPORTED NATIONAL OBESITY RATES HIGHER THAN STATE-BY-STATE RATES? How is it that only 6 states have adult study found that, due to this phenomenon, obesity rates exceeding 35 percent, BRFSS may underestimate obesity rates yet the national obesity rate is 39.6 by nearly 10 percent.83 NHANES, from percent? It’s because state obesity rates which the national obesity rate is derived, come from BRFSS, which collects self- calculates its obesity rate based on reported height and weight. Research physical examinations of respondents. has demonstrated that people tend Accordingly, the higher rates found by to overestimate their height and NHANES are a more accurate reflection of underestimate their weight. In fact, one obesity in the United States.84 ii. State Analysis Percent Change in Adult Obesity Rates by State, 2012-2017 State-level obesity rates vary considerably, from a low of 22.6 percent in Colorado WA to a high of 38.1 in West Virginia, MT ME according to 2017 BRFSS data.85 Other ND OR MN VT key findings include: ID NH SD WI NY MA WY MI l I n 2017, the adult obesity rate was at or CT RI NE IA PA NJ above 35 percent in seven states. Iowa NV IL OH DE UT IN CA MD and Oklahoma had adult obesity rates CO WV DC KS MO VA above 35 percent for the first time ever, KY NC while Alabama, Arkansas, Louisiana, AZ OK TN NM AR SC Mississippi, and West Virginia also had MS GA AL rates above 35 percent in 2016. TX LA l J ust two states — Hawaii and Colorado FL — and the District of Columba had AK adult obesity rates below 25 percent in Obesity rates increased <5% 2017. Nineteen states had adult obesity HI Obesity rates increased 5% – <10% rates between 25 and 30 percent and 22 Obesity rates increased 10% – <15% states were between 30 and 35 percent. SOURCE: BRFSS Obesity rates increased 15%+ l B etween 2016 and 2017, six states — Iowa, Massachusetts, Ohio, Oklahoma, significant decreases in their obesity Rhode Island, and South Carolina — rate over the last five years.86 had statistically significant increases in their obesity rates. The other 44 states l I n 1985, no state had an adult obesity and the District of Columbia had no rate higher than 15 percent; in 1991, statistically significant change in their no state was over 20 percent; in 2000, obesity rate between 2016 and 2017. no state was over 25 percent; in 2006, only Mississippi and West Virginia l B etween 2012 and 2017, the majority were above 30 percent.87 of states (31) had statistically significant increases in their obesity For additional state-level data from BRFSS, rates. No states had statistically see charts on pages 20 and 22. TFAH • RWJF 19 OBESITY AND OVERWEIGHT RATES ADULTS (2017) Obesity Overweight and Obesity Diabetes Hypertension Physical Activity Percent of Adults Percent of Percent of Percent of Adults Percent of Adults Who Have Obesity Ranking Who Have Obesity Adults Who Have Adults Who Have States Ranking Rank Rank Who Are Not Ranking or Are Overweight Diabetes Hypertension (95% CI) Physically Active (95% CI) (95% CI) (95% CI) Alabama 36.3 (+/-1.6) 5 70.2 (+/-1.6) 4 14.1 (+/-1.0) 3 41.9 (+/-1.6) 2 32.0 (+/-1.5) 6 Alaska 34.2 (+/-2.9) 9 66.7 (+/-2.9) 24 7.4 (+/-1.4) 49-T 31.8 (+/-2.6) 28 20.6 (+/-2.3) 48 Arizona 29.5 (+/-1.0) 30 64.8 (+/-1.1) 36 10.4 (+/-0.6) 29-T 30.7 (+/-0.9) 33 25.1 (+/-0.9) 30 Arkansas 35.0 (+/-2.4) 7 70.5 (+/-2.3) 3 12.2 (+/-1.29) 9 41.3 (+/-2.3) 3 32.5 (+/-2.4) 3 California 25.1 (+/-1.3) 48 60.9 (+/-1.5) 47 10.5 (+/-0.9) 24-T 28.4 (+/-1.3) 47 20.0 (+/-1.2) 49 Colorado 22.6 (+/-1.1) 51 58.7 (+/-1.3) 50 7.4* (+/-0.6) 49-T 25.9 (+/-1.0) 50 19.5 (+/-1.0) 50 Connecticut 26.9 (+/-1.2) 42 63.2 (+/-1.4) 40 9.8 (+/-0.7) 34 30.5 (+/-1.1) 36-T 24.0 (+/-1.2) 39-T Delaware 31.8 (+/-2.1) 23 68.5 (+/-2.2) 11 11.3 (+/-1.2) 14-T 34.9 (+/-2.0) 11 31.0 (+/-2.09) 9-T D.C. 23.0 (+/-1.6) 50 53.9 (+/-2.1) 51 7.8 (+/-0.9) 47-T 26.7 (+/-1.5) 48 23.0 (+/-1.7) 43 Florida 28.4 35-T 64.1 39 10.5** (+/-0.8) 24-T 34.6 (+/-1.4) 16 29.2 (+/-1.5) 14-T Georgia 31.6 (+/-1.6) 24-T 65.3 (+/-1.7) 30 11.4 (+/-0.9) 12-T 33.1 (+/-1.5) 17-T 31.0 (+/-1.6) 9-T Hawaii 23.8 (+/-1.4) 49 58.8 (+/-1.6) 49 10.9 (+/-0.9) 20 30.6 (+/-1.4) 34-T 23.5 (+/-1.39) 42 Idaho 29.3 (+/-1.8) 32 65.9 (+/-2.0) 27 8.7 (+/-0.9) 43 29.8 (+/-1.7) 41 24.2 (+/-1.7) 38 Illinois 31.1 (+/-1.6) 27 65.8 (+/-1.7) 28 11.0 (+/-1.0) 17-T 32.2 (+/-1.5) 26 24.0 (+/-1.5) 39-T Indiana 33.6 (+/-1.1) 12 68.0 (+/-1.1) 14-T 11.8 (+/-0.6) 11 35.2 (+/-1.0) 10 29.8 (+/-1.1) 12 Iowa 36.4* (+/-1.3) 4 70.1 (+/-1.3) 5 9.6 (+/-0.7) 35-T 31.5 (+/-1.2) 29 25.0 (+/-1.2) 31-T Kansas 32.4 (+/-0.8) 18 67.2 (+/-0.9) 20-T 10.5* (+/-0.5) 24-T 32.8 (+/-0.8) 20 27.9 (+/-0.8) 19 Kentucky 34.3 (+/-1.7) 8 67.8 (+/-1.7) 16-T 12.9 (+/-1.1) 7 39.4 (+/-1.6) 5 34.4 (+/-1.7) 1 Louisiana 36.2 (+/-1.8) 6 70.0 (+/-1.8) 6 13.6 (+/-1.2) 4 39.0 (+/-1.7) 6 31.8 (+/-1.8) 7 Maine 29.1 (+/-1.4) 33 65.1 (+/-1.6) 32 10.7 (+/-0.9) 21-T 34.8 (+/-1.4) 12 25.2 (+/-1.4) 29 Maryland 31.3 (+/-1.3) 26 66.2 (+/-1.4) 26 10.4 (+/-0.7) 29-T 32.4 (+/-1.2) 24-T 25.6 (+/-1.3) 26-T Massachusetts 25.9* 44 61.4 45 9.5 37 28.6 46 24.8 35 Michigan 32.3 (+/-1.2) 19 67.2 (+/-1.2) 20-T 11.0 (+/-0.7) 17-T 34.7 (+/-1.1) 13-T 27.2 (+/-1.1) 21-T Minnesota 28.4 (+/-0.9) 35-T 64.9 (+/-1) 33-T 7.8** (+/-0.5) 47-T 26.6 (+/-0.8) 49 24.6 (+/-0.9) 36 Mississippi 37.3 (+/-2.0) 2 69.9 (+/-2) 7 14.2 (+/-1.2) 2 40.8 (+/-1.9) 4 33.2 (+/-2.0) 2 Missouri 32.5 (+/-1.5) 17 67.8 (+/-1.6) 16-T 10.4 (+/-0.9) 29-T 32.0 (+/-1.4) 27 29.2 (+/-1.5) 14-T Montana 25.3 (+/-1.6) 46-T 62.2 (+/-1.8) 43-T 7.9 (+/-0.9) 46 29.0 (+/-1.5) 45 25.0 (+/-1.5) 31-T Nebraska 32.8 (+/-1.2) 15-T 69.0 (+/-1.2) 10 10.1* (+/-0.7) 33 30.6 (+/-1.1) 34-T 25.4 (+/-1.1) 28 Nevada 26.7 (+/-2.3) 43 65.7* (+/-2.4) 29 10.4 (+/-1.4) 29-T 32.6 (+/-2.2) 21-T 28.0 (+/-2.3) 18 New Hampshire 28.1 (+/-1.8) 38 64.9 (+/-2.0) 33-T 8.4 (+/-0.8) 44 30.0 (+/-1.6) 40 23.9 (+/-1.7) 41 New Jersey 27.3 (+/-1.5) 41 62.6 (+/-1.6) 41-T 11.0* (+/-0.9) 17-T 33.0 (+/-1.4) 19 29.0 (+/-1.5) 16 New Mexico 28.4 (+/-1.6) 35-T 65.2 (+/-1.8) 31 10.7 (+/-1.0) 21-T 30.5 (+/-1.5) 36-T 24.5 (+/-1.6) 37 New York 25.7 (+/-1.1) 45 61.3 (+/-1.3) 46 10.5 (+/-0.7) 24-T 29.4 (+/-1.1) 44 27.2 (+/-1.2) 21-T North Carolina 32.1 (+/-1.8) 20 66.9 (+/-1.8) 23 11.4 (+/-1.1) 12-T 34.7 (+/-1.7) 13-T 25.6 (+/-1.7) 26-T North Dakota 33.2 (+/-1.6) 13 69.4 (+/-1.6) 8-T 9.0 (+/-0.8) 40-T 29.5 (+/-1.3) 42-T 27.6 (+/-1.5) 20 Ohio 33.8* (+/-1.3) 11 68.0 (+/-1.3) 14-T 11.3 (+/-0.7) 14-T 34.7 (+/-1.2) 13-T 29.6 (+/-1.3) 13 Oklahoma 36.5* (+/-1.6) 3 70.6 (+/-1.5) 2 12.7 (+/-0.9) 8 37.7 (+/-1.5) 9 32.4 (+/-1.5) 4 Oregon 29.4 (+/-1.5) 31 64.5 (+/-1.6) 38 9.6 (+/-0.9) 35-T 30.1 (+/-1.4) 39 21.4 (+/-1.4) 46 Pennsylvania 31.6 (+/-1.6) 24-T 67.1 (+/-1.6) 22 10.6 (+/-0.9) 23 32.6 (+/-1.5) 21-T 24.9 (+/-1.5) 33-T Rhode Island 30.0* (+/-1.9) 29 64.9 (+/-2) 33-T 8.9 (+/-0.9) 42 33.1 (+/-1.7) 17-T 26.3 (+/-1.79) 23 South Carolina 34.1* (+/-1.3) 10 68.1 (+/-1.3) 13 13.4 (+/-0.8) 5 38.1 (+/-1.2) 8 28.4 (+/-1.2) 17 South Dakota 31.9 (+/-2.1) 22 67.7 (+/-2.2) 18 11.1* (+/-1.3) 16 30.8 (+/-1.9) 30-T 24.9 (+/-1.9) 33-T Tennessee 32.8 (+/-1.8) 15-T 68.3 (+/-1.8) 12 13.1 (+/-1.1) 6 38.7 (+/-1.7) 7 30.6 (+/-1.7) 11 Texas 33.0 (+/-1.8) 14 69.4 (+/-1.8) 8-T 11.9 (+/-1.2) 10 32.5 (+/-1.7) 23 32.1 (+/-1.9) 5 Utah 25.3 (+/-1.1) 46-T 60.6 (+/-1.3) 48 7.1 (+/-0.6) 51 24.5 (+/-1.0) 51 21.1 (+/-1.0) 47 Vermont 27.6 (+/-1.6) 40 62.6 (+/-1.8) 41-T 8.2 (+/-0.8) 45 30.4 (+/-1.5) 38 21.6 (+/-1.5) 45 Virginia 30.1 (+/-1.4) 28 66.3 (+/-1.5) 25 10.5 (+/-0.7) 24-T 32.4 (+/-1.29) 24-T 25.9 (+/-1.3) 24 Washington 27.7 39 62.2 43-T 9.1 38-T 29.5 42-T 19.2 51 West Virginia 38.1 (+/-1.7) 1 71.7 (+/-1.6) 1 15.2 (+/-1.0) 1 43.5 (+/-1.6) 1 31.6 (+/-1.5) 8 Wisconsin 32.0 21 67.3 19 9.1 (+/-1.0) 38-T 30.8 (+/-1.6) 30-T 22.4 (+/-1.6) 44 Wyoming 28.8 (+/-1.7) 34 64.7 (+/-1.9) 37 9.0 (+/-0.9) 40-T 30.8 (+/-1.6) 30-T 25.7 (+/-1.6) 25 Note: Red and * indicates state rate significantly increased between 2016 and 2017; Green and ** indicates state rate significantly decreased between 2016 and 2017; bold indicates state rates signficantly increased between 2012 and 2017. Test of signfnicance were not conducted for hypertesion and physical activity. CI=Confidence Intervals; if not referenced, confidence intervals could not be calculated. For rankings, 1=Higest rate and 51=Lowest rate. Source: BRFSS 20 TFAH • RWJF AND RELATED HEALTH INDICATORS CHILDREN AND ADOLESCENTS Households: Young Children: Children and Teenagers: High School (HS) Students: Food Insecurity Obesity (2014) Obesity and Physical Activity (2016) Obesity, Overweight, Physical Activity (2017) (2014-2016) Percent of Low- Percent of Percent of Children Ages Percent of HS Percent of HS Percent of HS Students Who Are Physically Active Householdsof Percent Income Children Children Ages Ranking 6-11 Who Participate in Students Who Students Who Are States with Ages 2-4 Who 10-17 Who Have 60 Minutes of Physical Have Obesity Overweight 60 Minutes On All 7 Days Food Insecurity Have Obesity Obesity Activity Everyday (95% CI) (95% CI) (95% CI) Alabama 16.3 18.2 12-T 40.0 N/A N/A N/A 18.1 Alaska 19.1 15.4 24 31.7 13.7 (+/-1.1) 17.5 (+/-2.55) 18.4 (+/-2.65) 12.7 Arizona 13.3 15.9 22 22.9 12.3 (+/-2.25) 15.9 (+/-2.85) 24.5 (+/-2.75) 14.6 Arkansas 14.4 19.1 8 29.6 21.7 (+/-4.2) 18.1 (+/-1.95) 21.4 (+/-6.05) 17.5 California 16.6 16.1 21 30.5 13.9 (+/-3.85) 15.0 (+/-1.9) 27.5 (+/-3.3) 11.8 Colorado 8.5 9.0 49 28.8 9.5 (+/-2.1) 12.3 (+/-2.05) 27.4 (+/-3.55) 10.3 Connecticut 15.3 13.4 37-T 32.2 12.7 (+/-2.1) 16.0 (+/-3.1) 22.3 (+/-2.1) 12.3 Delaware 17.2 16.8 18 29.5 15.1 (+/-2.15) 16.6 (+/-1.65) 25.1 (+/-2.45) 10.8 D.C. 13.0 16.3 20 23.8 16.8 (+/-0.95) 18.0 (+/-1.0) 13.4 (+/-0.9) 11.4 Florida 12.7 17.9 15 32.5 10.9 (+/-1.4) 14.2 (+/-1.0) 22.8 (+/-1.2) 12.0 Georgia 13.0 18.6 9-T 36.4 N/A N/A N/A 14.0 Hawaii 10.3 11.0 46 25.1 14.2 (+/-1.15) 14.2 (+/-1.65) 19.6 (+/-1.6) 8.7 Idaho 11.6 14.9 26-T 30.8 11.4 (+/-1.8) 14.7 (+/-2.25) 23.7 (+/-1.95) 12.1 Illinois 15.2 14.9 26-T 31.2 14.8 (+/-2.45) 16.1 (+/-2) 23.2 (+/-3.45) 11.1 Indiana 14.3 18.5 11 36.3 N/A N/A N/A 15.2 Iowa 14.7 17.5 16 26.0 15.3 (+/-3.75) 16 (+/-2.3) 29.4 (+/-3.85) 10.7 Kansas 12.8 11.6 45 32.0 13.1 (+/-3.35) 15.3 (+/-1.95) 26.5 (+/-3.35) 14.5 Kentucky 13.3 19.6 4 30.2 20.2 (+/-2.95) 16.1 (+/-2) 22 (+/-2.55) 17.3 Louisiana 13.2 19.2 5-T 25.4 17 (+/-3.05) 18.3 (+/-2.25) 20.5 (+/-4) 18.3 Maine 15.1 13.9 35-T 36.0 14.3 (+/-1.2) 16 (+/-1.15) 19.6 (+/-1.15) 16.4 Maryland 16.5 16.9 17 27.1 12.6 (+/-0.5) 15.2 (+/-0.45) 17.9 (+/-0.5) 10.1 Massachusetts 16.6 15.0 25 28.1 11.7 (+/-1.95) 14.0 (+/-1.6) 22.7 (+/-2.6) 10.3 Michigan 13.4 13.9 35-T 32.3 16.7 (+/-4.25) 16.3 (+/-1.7) 22.9 (+/-2.45) 14.3 Minnesota 12.3 13.4 37-T 32.6 N/A N/A N/A 9.7 Mississippi 14.5 26.2 1 34.3 N/A N/A N/A 18.7 Missouri 13.0 14.0 34 29.6 16.6 (+/-3.05) 15.7 (+/-2.25) 28.6 (+/-3.65) 14.2 Montana 12.5 12.4 43 30.3 11.7 (+/-1.4) 14.6 (+/-1.35) 28.0 (+/-1.45) 12.9 Nebraska 16.9 16.7 19 36.4 14.6 (+/-2.4) 16.6 (+/-3.15) 26.8 (+/-3.35) 14.7 Nevada 12.0 14.5 31 31.0 14.0 (+/-2.25) 14.3 (+/-2.8) 24.9 (+/-0.25) 12.1 New Hampshire 15.1 8.5 51 30.1 12.8 (+/-0.95) 14.1 (+/-0.95) 23.0 (+/-0.95) 9.6 New Jersey 15.3 14.8 28-T 24.7 N/A N/A N/A 11.1 New Mexico 12.5 13.1 39 31.8 15.3 (+/-1.65) 16.4 (+/-1.55) 30.8 (+/-2.45) 17.6 New York 14.3 14.8 28-T 22.9 12.4 (+/-1.85) 16.2 (+/-1.75) 23.2 (+/-2.55) 12.5 North Carolina 15.0 12.6 42 32.5 15.4 (+/-2.2) 15.5 (+/-2.1) 22.3 (+/-2.2) 15.1 North Dakota 14.4 15.8 23 34.8 14.9 (+/-1.75) 16.2 (+/-2.1) 26.1 (+/-2.3) 8.8 Ohio 13.1 18.6 9-T 34.9 N/A N/A N/A 14.8 Oklahoma 13.8 18.1 14 30.8 17.1 (+/-2.95) 16.5 (+/-1.95) 29.5 (+/-3.65) 15.2 Oregon 15.0 10.2 47 29.7 N/A N/A N/A 14.6 Pennsylvania 12.9 14.2 32 30.8 13.7 (+/-1.9) 15.7 (+/-1.9) 24.5 (+/-2.55) 12.5 Rhode Island 16.3 19.2 5-T 28.2 15.2 (+/-2.8) 15.9 (+/-2.7) 23.2 (+/-3.85) 12.8 South Carolina 12.0 18.2 12-T 31.3 17.2 (+/-3.2) 16.5 (+/-2.7) 21.7 (+/-3.8) 13.0 South Dakota 17.1 13.0 40 31.9 N/A N/A N/A 10.6 Tennessee 14.9 19.2 5-T 29.6 20.5 (+/-2.6) 17.5 (+/-1.9) 25.6 (+/-2.65) 13.4 Texas 14.9 21.3 2 23.8 18.6 (+/-2.45) 18.0 (+/-2.3) 25.2 (+/-3.35) 14.3 Utah 8.2 9.5 48 21.9 9.6 (+/-1.7) 13.2 (+/-1.4) 19.1 (+/-3.3) 11.5 Vermont 14.1 11.8 44 39.7 12.6 (+/-0.45) 14.1 (+/-0.5) 25.4 (+/-0.6) 10.1 Virginia 20.0 14.1 33 29.9 12.7 (+/-1.8) 15.5 (+/-1.55) 22.4 (+/-1.95) 9.9 Washington 13.6 8.7 50 33.7 N/A N/A N/A 11.6 West Virginia 16.4 19.9 3 32.1 19.5 (+/-3.15) 16.0 (+/-2.55) 23.4 (+/-1.4) 14.9 Wisconsin 14.7 14.6 30 32.5 13.7 (+/-1.0) 15.0 (+/-1.5) 24.7 (+/-3.1) 10.7 Wyoming 9.9 12.9 41 29.2 N/A N/A N/A 12.7 Source: WIC Participants Note: For ranking, 1=Highest rate and 51=Lowest rate. Note: CI= Confidence Intervals Source: USDA, 2014-2016 and Program Source: NSCH, 2016 Source: YRBS, 2017 Characteristics Surrvey, 2014 TFAH • RWJF 21 OBESITY PREVALENCE BY AGE AND RACE/ETHNICITY (2017) Ages 18-24 Ages 25-44 Ages 45-64 Ages 65+ Black Latino White Percent Who Percent Who Percent Who Percent Who Percent Who Percent Who Have Percent Who Have Have Obesity Rank Have Obesity Rank Have Obesity Rank Have Obesity Rank Rank Rank Have Obesity Rank Obesity (95% CI) Obesity (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Alabama 20.7 11 39.2 3 44.1 (+/-2.6) 2 29.0 (+/-2.3) 27-T 45.0 (+/-1.9) 3 31.9 20-T 33.1 (+/-1.1) 7 Alaska 23.0 4 35.8 (+/-5.4) 10 36.9 (+/-4.2) 24 34.8 (+/-5.0) 1 44.7 4 28.8 (+/-7.8) 37-T 30.0 (+/-1.7) 21-T Arizona 18.2 18 32.4 21 34.0 (+/-1.6) 34-T 25.5 (+/-1.4) 43 32.4 34 35.5 (+/-2.0) 7 26.1 (+/-0.8) 39 Arkansas 13.3 (+/-6.7) 44-T 40.3 (+/-5.4) 2 41.4 (+/-3.6) 7 30.6 (+/-3.1) 16-T 44.2 (+/-4.3) 5 30.1 (+/-8.2) 29 34.0 (+/-1.5) 3 California 12.7 (+/-3.2) 49 24.0 (+/-2.1) 49 31.7 (+/-2.4) 39 24.2 (+/-2.8) 46-T 31.4 (+/-3.2) 36 32.1 (+/-1.2) 19 23.1 (+/-0.9) 48 Colorado 13.1 46 22.0 50 27.0 50 22.4 49 28.9 42 27.4 47 20.3 (+/-0.7) 49 Connecticut 16.2 (+/-4.3) 30-T 27.1 (+/-2.6) 45 30.8 (+/-1.8) 43 26.4 (+/-2.0) 41 37.1 (+/-2.9) 24-T 31.8 (+/-2.3) 25 24.4 (+/-0.8) 44 Delaware 15.5 38 31.3 (+/-4.5) 27 36.1 (+/-3.5) 26-T 33.9 (+/-3.3) 3 37.4 (+/-3.2) 23 31.9 (+/-4.7) 20-T 29.7 (+/-1.4) 24 D.C. 16.0 (+/-5.5) 32 20.6 (+/-2.7) 51 29.6 (+/-2.7) 49 24.2 (+/-3.0) 46-T 36.2 (+/-1.9) 29 19.7 (+/-4.9) 51 10.4 (+/-1.4) 51 Florida 17.1 25-T 29.0 35-T 34.0 (+/-2.6) 34-T 25.4 (+/-2.2) 44 35.4 30 28.1 43 26.2 (+/-0.8) 38 Georgia 16.9 28 33.0 19 37.3 (+/-2.7) 23 29.3 24-T 37.1 24-T 29.9 30-T 29.5 (+/-1.2) 26 Hawaii 15.9 33-T 27.6 41 25.5 (+/-2.2) 51 19.8 (+/-2.4) 51 29.8 (+/-10.0) 40 31.9 20-T 17.5 (+/-1.3) 50 Idaho 16.2 30-T 30.4 (+/-3.7) 31 35.9 (+/-3.1) 28 26.1 (+/-2.8) 42 n/a - 33.7 12 27.8 (+/-1.1) 33 Illinois 13.6 43 30.5 (+/-3.1) 30 38.8 (+/-2.7) 12 30.2 (+/-2.5) 22 39.5 (+/-2.9) 17 35.9 (+/-3.0) 6 30.3 (+/-1.1) 18 Indiana 20.5 12 33.8 (+/-2.2) 15 38.7 (+/-1.7) 13-T 33.3 (+/-1.6) 5 42.2 8 28.2 42 32.1 (+/-0.9) 8-T Iowa 22.6 5 38.4 5 42.8 4 32.5 7 36.3 28 33.4 13 33.6 (+/-0.9) 4 Kansas 21.9 8 33.5 16 37.7 (+/-1.3) 21 29.3 (+/-1.3) 24-T 41.2 10 36.8 3-T 32.0 (+/-0.6) 10 Kentucky 20.3 13 37.3 6-T 38.2 (+/-2.8) 18-T 31.5 (+/-2.9) 13 40.2 13 28.5 40 34.4 (+/-1.0) 2 Louisiana 21.0 10 36.5 9 42.9 (+/-3.0) 3 34.2 2 42.6 (+/-2.4) 7 32.3 17 33.4 (+/-1.3) 5-T Maine 12.9 48 29.7 33 34.3 (+/-2.2) 32 27.8 (+/-2.1) 34 24.8 45 32.2 18 29.8 (+/-0.8) 23 Maryland 18.4 (+/-4.5) 17 31.1 29 36.1 (+/-1.89) 26-T 31.2 (+/-1.9) 14 39.1 (+/-1.7) 18-T 27.6 (+/-4.0) 46 28.1 (+/-0.9) 30 Massachusetts 9.5 51 27.3 (+/-3.5) 42 30.1 (+/-3.0) 47 26.8 38-T 35.1 31 31.0 (+/-2.9) 28 24.0 46-T Michigan 18.1 19 32.2 23 37.5 22 32.4 (+/-2.0) 8-T 39.9 14-T 38.6 1 30.9 (+/-0.7) 17 Minnesota 15.2 40 28.7 (+/-1.8) 37 32.6 (+/-1.5) 37 28.8 (+/-1.5) 29 30.4 (+/-3.0) 39 33.3 (+/-3.2) 14 27.5 (+/-0.5) 34 Mississippi 24.2 3 40.5 1 42.2 (+/-3.1) 5 33.1 (+/-2.8) 6 45.4 (+/-2.0) 2 29.2 34-T 32.1 (+/-1.3) 8-T Missouri 19.4 14 32.8 20 38.7 (+/-2.6) 13-T 29.8 (+/-2.3) 23 39.1 18-T 29.9 30-T 31.6 (+/-1.0) 14 Montana 14.2 42 25.6 (+/-3.2) 46 30.6 (+/-2.7) 44 23.1 (+/-2.5) 48 n/a - 26.0 (+/-6.8) 49 24.0 (+/-1.0) 46-T Nebraska 18.0 20 33.3 18 39.1 11 31.8 12 39.9 14-T 32.8 16 31.7 (+/-0.7) 13 Nevada 17.4 (+/-6.3) 23 27.2 (+/-4.3) 43-T 30.0 (+/-4.0) 48 25.0 (+/-3.6) 45 29.2 (+/-5.0) 41 29.2 (+/-3.2) 34-T 25.7 (+/-1.6) 40-T New Hampshire 17.1 25-T 29.3 34 30.3 (+/-2.5) 45-T 29.0 (+/-2.5) 27-T 25.9 44 24.1 50 27.4 (+/-1.0) 35 New Jersey 15.3 39 27.2 (+/-3.1) 43-T 31.4 (+/-2.2) 41 26.6 (+/-2.2) 40 36.4 (+/-2.6) 27 31.9 20-T 25.7 (+/-1.0) 40-T New Mexico 17.1 25-T 32.3 (+/-3.3) 22 33.8 (+/-2.7) 36 21.6 (+/-2.3) 50 31.2 37 31.2 (+/-1.7) 27 24.3 (+/-1.3) 45 New York 12.3 50 25.0 (+/-2.1) 47-T 30.3 (+/-1.9) 45-T 26.9 (+/-2.1) 36-T 33.4 33 28.7 39 24.7 (+/-0.7) 42-T North Carolina 15.6 36-T 33.4 17 38.2 18-T 30.3 20-T 41.1 (+/-2.2) 11 28.3 41 29.3 (+/-1.1) 27-T North Dakota 21.5 9 34.6 (+/-3.1) 14 38.3 (+/-2.3) 17 32.1 (+/-2.2) 10 19.6 (+/-7.5) 47 36.5 (+/-8.4) 5 31.9 (+/-1.0) 11 Ohio 18.9 16 35.5 11 39.5 (+/-2.1) 9 30.9 (+/-2.0) 15 37.5 (+/-2.7) 22 31.9 20-T 31.2 (+/-0.8) 15 Oklahoma 28.2 1 37.3 (+/-3.1) 6-T 41.9 (+/-2.6) 6 31.9 (+/-2.2) 11 37.6 (+/-3.9) 21 36.8 3-T 33.4 (+/-1.0) 5-T Oregon 17.9 (+/-4.8) 21 28.0 (+/-2.8) 40 34.2 (+/-2.7) 33 30.3 (+/-2.7) 20-T 30.8 (+/-9.2) 38 34.9 (+/-3.9) 9 29.3 (+/-1.0) 27-T Pennsylvania 15.9 33-T 31.4 (+/-3.0) 26 36.7 (+/-2.6) 25 32.4 (+/-2.9) 8-T 36.8 26 34.7 10 30.1 (+/-1.0) 19-T Rhode Island 15.8 35 31.6 (+/-3.9) 24 35.0 (+/-2.8) 31 28.3 (+/-2.7) 32 31.8 35 33.1 15 26.9 (+/-1.1) 36 South Carolina 22.3 7 36.7 8 39.8 (+/-2.0) 8 28.7 (+/-1.7) 30 42.0 (+/-1.6) 9 27.8 45 29.6 (+/-0.9) 25 South Dakota 19.3 15 31.2 28 38.5 15-T 30.4 (+/-3.3) 19 n/a - 35.0 8 30.0 (+/-1.2) 21-T Tennessee 15.6 36-T 34.9 12 38.5 (+/-2.9) 15-T 30.6 (+/-2.9) 16-T 46.4 (+/-3.4) 1 29.6 33 31.8 (+/-1.1) 12 Texas 16.4 29 34.8 13 39.2 (+/-3.2) 10 30.6 (+/-3.8) 16-T 39.8 16 37.9 (+/-1.9) 2 30.1 (+/-1.3) 19-T Utah 13.3 44-T 25.0 47-T 31.8 38 26.8 38-T 26.3 43 27.9 44 24.7 (+/-0.7) 42-T Vermont 14.3 41 29.0 (+/-3.5) 35-T 31.6 (+/-2.4) 40 27.4 (+/-2.6) 35 22.8 46 26.4 48 26.7 (+/-0.9) 37 Virginia 17.7 22 30.3 32 35.6 (+/-2.2) 29 28.2 33 41.0 12 29.9 30-T 27.9 (+/-0.9) 31-T Washington 17.3 24 28.3 39 31.3 42 26.9 36-T 33.7 32 33.9 11 28.3 (+/-0.6) 29 West Virginia 24.5 (+/-6.6) 2 39.0 (+/-3.4) 4 45.0 (+/-2.5) 1 33.5 (+/-2.5) 4 43.6 (+/-5.6) 6 29.0 (+/-9.0) 36 37.0 (+/-0.9) 1 Wisconsin 22.5 6 31.5 25 38.1 20 29.1 26 38.1 20 31.5 26 31.0 (+/-1.0) 16 Wyoming 13.0 47 28.6 (+/-3.4) 38 35.4 (+/-2.8) 30 28.6 (+/-2.7) 31 n/a - 28.8 (+/-4.9) 37-T 27.9 (+/-1.1) 31-T Note: For ranking, 1=Highest rate and 51=Lowest rate. CI=Confidence Intervals; if not referenced, confidence intervals could not be calculated. Race/ethnicity data is averaged over three years (2015-2017) ir order to get a sufficient sample. Source: BRFSS, 2017 22 TFAH • RWJF B. TRENDS IN CHILDHOOD OBESITY Children who are overweight or the United States are not eating enough have obesity are more likely to have nutritious foods or getting sufficient obesity as adults.88 As such, targeting physical activity.89,90,91 interventions that will help families and This section includes the latest data young children have access to healthy, available on childhood obesity. As with affordable foods and safe places for adults, this report relies on multiple physical activity is a promising strategy surveys to better understand the full for addressing America’s obesity picture of childhood obesity. epidemic. Like adults, most children in DATA SOURCES FOR CHILDHOOD OBESITY MEASURES 1) The National Health and Nutrition 3) he National Survey of Children’s T Examination Survey is the primary Health (NSCH) surveys parents source for national obesity data on of children ages 0 to 17 about adults and on children ages 2 to 19 aspects of their children’s health, in this report. NHANES is particularly including height and weight. An valuable in that it combines advantage of this survey is that interviews with physical examinations it includes state-level data. A while also covering a wide age range disadvantage is that height and of Americans. The downsides of the weight data are parent-reported, not survey include a time delay from directly measured. The NSCH survey collection to reporting and samples is now annual and the most recent that do not break out local data. The data are from its 2016 iteration. most recent NHANES data are from Because survey methodology the 2015–2016 survey. changed in 2016, it is not possible to compare 2016 estimates to 2) he WIC Participant and Program T earlier iterations of the survey. Characteristics Report is a biennial census of families who are served by 4) The Youth Risk Behavior Survey the Special Supplemental Nutrition (YRBS) measures high-risk health Program for WIC. USDA collects the behaviors among students in grades data, and CDC analyzes the obesity 9 to 12, including eating habits, data. Because the program only physical activity, and obesity (by asking includes low-income mothers and respondents to self-report about their young children (under the age of 5), height and weight). As in other surveys this dataset is limited. Nevertheless, 92 that use self-reported data to measure because obesity disproportionately obesity, this survey likely underreports affects individuals with low incomes, the true rates.93 YRBS is conducted early childhood is a critical time for in odd-numbered years; 2017 is the obesity prevention, and the dataset most recent dataset available. The provides valuable information for 2017 survey includes state-level evaluating the effectiveness of samples for 39 states and the District programs aimed at reducing obesity of Columbia plus select large urban rates and health disparities. The most school district, as well as a separate recent public WIC data are from 2014. national sample.94 TFAH • RWJF 23 i. National Childhood Obesity Rates NHANES data show that 18.5 percent of children ages 2 to 19 had obesity Percent of Children With Obesity, 1976–2016 in 2015–16, the highest rate ever 50% documented by NHANES. Since the 1976–1980 NHANES survey, overall 40% childhood obesity rates have more 30% than tripled, up from 5.5 percent. The 20% 17.1% 15.4% 16.8 16.9% 16.9% 17.2% 18.5% percentage of 2- to 5-year-olds with 13.9% 15.4% 10.0% obesity more than doubled, from 5 to 10% 5.5% 13.9 percent, as did the percentage of 6- to 11-year-olds with obesity, from 6.5 0% 80 94 00 02 04 06 08 10 12 14 16 to 18.4 percent. And the obesity rates 6-19 -19 9-20 1-20 3-20 5-20 7-20 9-20 -20 3-20 -20 97 98 8 99 00 00 00 00 00 01 1 01 15 1 1 1 2 2 2 2 2 2 2 20 of teens ages 12 to 19 quadrupled, Source: NHANES from 5 to 20.6 percent.95,96,97 Percent of Children With Obesity, by Demographic Group, 2015–2016 Since the 1976–1980 NHANES 50% survey, overall childhood obesity 40% rates have more than tripled, up 30% from 5.5 percent. 25.8% 20.6% 22.0% 20% 18.5% 19.1% 17.8% 18.4% 13.9% 14.1% NHANES provides key breakdowns by 11.0% 10% subgroups, including: l ace/ethnicity: There are substantial R 0% All Children Boys Girls Ages 2-5 Ages 6-11 Ages 12-19 Asian Black Latino White differences in obesity rates among Children Children Children Children children of different races and Source: NHANES ethnicities: • besity rates are higher among O l ex: Boys are slightly more likely to S l ge: The prevalence of obesity and A Latino children (25.8 percent) and have obesity than girls. severe obesity increases with age. Black children (22.0 percent) than among White children (14.1 percent) • n 2015–2016, 19.1 percent of boys I • n 2015–2016, 13.9 percent of children I and Asian children (11.0 percent).98 had obesity and 17.8 percent of girls ages 2 to 5, 18.4 percent of children had obesity. ages 6 to 11, and 20.6 percent of • atino boys (28.0 percent) and Black L • etween 2013–2014 and 2015–2016, B children ages 12 to 19 had obesity. girls (25.1 percent) are most likely to have obesity. the obesity rate of boys went up 11 • Nearly 2 percent of children ages 2 percent, while the rate of girls with to 5, 5.2 percent of children ages 6 to obesity went up 4 percent.99 11, and 7.7 percent of children ages 12 to 19 had severe obesity. 24 TFAH • RWJF ii. Early Childhood Obesity Rates According to WIC data, the percent of 2- to 4-year-old children enrolled in the Percent of Young Children in WIC Program With Obesity, Overall and program who had obesity declined from by Race/Ethnicity, 2010–2014 30% 15.9 percent in 2010 to 14.5 in 2014. This decrease is statistically significant. And 25% these reductions were widespread—rates decreased among children in most states 20% and among all major racial and ethnic 19.3% groups. The drops were statistically 17.3% 15% 15.9% significant in 31 states, while just four states 14.5% had statistically significant increases.100 12.5% 12.7% 11.9% 12.8% 12.2% 10% 11.1% The obesity rates among children enrolled in WIC are still much higher 5% than the general population of children, and certain races and ethnicities have 0% All Children Asian Children Black Children Latino Children White Children much higher obesity rates than the ■ 2010 ■ 2014 overall population. Specifically, in 2014, Source: WIC 18.0 percent of American Indian/Alaska Native and 17.3 of Latino children who were enrolled in WIC had obesity, compared with 12.2 percent of White, 11.9 percent of Black and 11.1 percent of Asian/Pacific Islander children. iii. Obesity Rates in Children Ages 10 to 17 In 2016, the NSCH reported that Percent Of Children Age 10-17 With Obesity, 2016 nationwide, 16.1 percent of children ages 10 to 17 had obesity and 15 percent WA were overweight. The states with the MT ND ME highest rates of obesity for 10- to 17-year- OR MN VT ID NH olds were Mississippi (26.2 percent), SD WI NY MA WY MI Texas (21.3 percent), and West Virginia CT RI NE IA PA NJ (19.9 percent); the states with the lowest NV IL OH DE UT IN CA MD rates of obesity were New Hampshire CO WV DC KS MO VA (8.5 percent), Washington (8.7 percent), KY NC and Colorado (9 percent). See chart on AZ OK TN NM AR SC page 21 for more state data. MS GA AL TX LA <10% FL 10% – <15% AK 15% – < 20% 20%+ HI Source: NSCH TFAH • RWJF 25 iv. High School Obesity Rates According to 2017 YRBS data, 14.8 percent in Colorado to 21.7 percent percent of high school students (grades in Arkansas. This the first time that 9-12) nationwide had obesity and 15.6 YRBS identified states with high percent were overweight. In 2015, YRBS school obesity rates above 20 percent, found 13.9 percent of high schoolers had including in Arkansas (21.7 percent), obesity and 16.0 were overweight. Obesity Kentucky (20.2 percent), and levels among high school students show Tennessee (20.5 percent). a statistically significant increase in the l S tates with the highest level of high long-term; in 1999, obesity rates among school obesity—all in the South—were: high schoolers participating in the survey Arkansas (21.7 percent), Kentucky (20.2 were at 10.6 percent.101 percent), Louisiana (17.0 percent), Other takeaways include: Oklahoma (17.1 percent), South Carolina (17.2 percent), Tennessee l H igh schoolers who were male (17.5 (20.5 percent), Texas (18.6 percent), percent), Black (18.2 percent), Latino and West Virginia (19.5 percent).102 (18.2 percent), and lesbian, gay or bisexual (LGB) (20.5 percent) had l S tates with the lowest high school particularly high levels of obesity in obesity rates were: Colorado (9.5 2017. Male students who were Latino percent), Florida (10.9 percent), (22.2 percent) and male students Idaho (11.4 percent), Massachusetts who were LGB (21.9 percent) had the (11.7 percent), Montana (11.7 highest rates among these groups. percent), and Utah (9.6 percent). l T he levels of obesity among high See page 21 for state-by-state data on obesity, school students in different states overweight, and activity levels among high varied considerably—from 9.5 school students. Percent of High Schoolers with Obesity, Overall and by Race/Ethnicity, 1999–2017 20% 18.2% 18.2% 15% 13.2% 14.8% 12.3% 12.5% 10.6% 10% 10.0% 7.9% 5% 3.6% 0% 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 All Asian Black Latino White Source: YRBS 26 TFAH • RWJF SECTI O N 4 The State of SECTION 4: OBESITY-RELATED PROGRAMS AND POLICIES Obesity-Related Programs and Policies Obesity Scientists predict that, if current trends continue, more than half of today’s children will have obesity by age 35.103 A variety of public policy interventions can help alter this alarming trajectory. When schools serve nutritious meals to students, kids eat healthier foods. When nutrition information is available to consumers, they can make informed decisions about the foods they buy and eat. When schools set aside time for physical education and recess, kids are more active throughout the school day. There is growing evidence that a comprehensive, long-term approach to promoting healthy eating and physical activity in schools and communities can have a positive impact on health and well-being. The policies and programs described below play a key role in addressing America’s obesity epidemic. A. NUTRITION ASSISTANCE One of the most efficient and effective low-income Americans. Some of these ways to help Americans eat a well- programs provide nutritious food that balanced diet is to provide them with meets specific dietary guidelines, and/ healthy food. The federal government or have educational components to spends billions of dollars each year teach beneficiaries about healthy eating. on nutrition assistance programs for SEPTEMBER 2018 Jonathan Weiss / Shutterstock.com i. Women, Infants, and Children Program The Special Supplemental Nutrition later in life.108,109 WIC’s Farmers’ Market Program for Women, Infants, and Nutrition Program provides fresh, locally Children (WIC) provides federal funds to grown produce to participants and has states for nutrition and education services been proven to increase fresh fruit and for low-income pregnant, postpartum, vegetable consumption.110 Nationwide, and breastfeeding women and their only about one-third of Farmers’ Markets children under the age of 5. WIC is one participate in the program.111 of the largest federal nutrition programs, Congress requires USDA’s Food serving nearly 7.3 million women, infants, and Nutrition Service (FNS), which and children annually.104 administers WIC on the federal level, to periodically reevaluate the program’s food packages to ensure they align with the latest U.S. dietary guidelines. As part of this process, in 2017, the National Academies of Sciences, Engineering and Medicine recommended additional improvements to the WIC food package. The recommendations include providing more fish; increasing whole grains, fruits, and vegetables; and reducing sodium and saturated fat. The report also recommends more flexibility in providing infant formula in order to promote breastfeeding. These recommendations build on changes previously made to the WIC food package in 2009, which were the first major changes since the program’s inception.112 The 2009 changes are State agencies administer WIC, which associated with improved nutritional helps its recipients achieve and maintain purchases among WIC households, a healthy weight by providing healthy including fewer calories and less foods and nutrition education; promoting sodium, total fats, and added sugars.113 breastfeeding and supporting nursing The omnibus spending bill passed by mothers; and providing healthcare and Congress in March 2018, which funded social-service referrals. Research has the federal government for the remainder demonstrated WIC’s success.105 One of fiscal year (FY) 2018, appropriated study found that WIC recipients who $6.175 billion for WIC, including a set- received postpartum benefits were aside of $60 million for breastfeeding less likely to have obesity in their next initiatives, and an additional $18.5 million pregnancy.106 Another study found for the WIC Farmers’ Market Nutrition that breastfeeding rates among WIC Program.114 The total was $175 million recipients increased between 1994 and below the FY 2017 funding level, and 2013.107 Breastmilk is the best source of the bill also rescinded $800 million in nutrition for most infants, and breastfed unspent WIC funds. children have a reduced risk of obesity 28 TFAH • RWJF ii. Child Nutrition Programs Child nutrition programs provide food receive cash subsidies—and, in some for more than 34 million American programs, USDA-purchased foods—for children each year.115 The federal each meal they serve that meets federal government funds these programs, nutrition standards; eligible participants which are administered by the FNS and receive free or reduced-price meals state agencies. Participating providers through these programs. MAJOR CHILD NUTRITION PROGRAMS IN THE UNITED STATES l T he Child and Adult Care Food l T he Summer Food Service Program Program (CACFP) funds healthy provides nutritious daily meals during meals and snacks for approximately summer vacation to approximately 4.2 million children in daycare, 2.6 million students from low-income preschool, and aftercare programs, families.119,120 as well as 130,000 adults in adult l T he Special Milk Program for Children daycare centers.116 provides free low-fat or skim milk to l he National School Lunch Program T students who do not participate in provides meals and snacks to more school meal programs, such as half- than 30 million students in public day kindergarten students.121 schools, private schools, and residential l T he Fresh Fruit and Vegetable Program child-care facilities. Approximately 75 provides fresh fruits and vegetables to percent of these students qualify for select low-income schools.122 free or reduced-price meals.117 l T he Farm to School Program brings l T he School Breakfast Program fresh, local food into school cafeterias provides breakfast to nearly 14.6 and facilitates hands-on learning million students. Approximately 85 activities, including school gardens, percent of these students qualify for farm visits, and cooking classes.123 free or reduced-price meals.118 Because of the success of these align school food nutrition standards programs, nutrition advocates are with the updated Dietary Guidelines working toward increasing participation for Americans.126,127 The rules require rates, particularly in the School Breakfast increased availability of whole grains, Program. Although more than 90 fruits and vegetables, skim and low-fat percent of schools that participate in milk, and lower levels of added sugars the school lunch program also offer and saturated fats.128,129 The school lunch breakfast, only 57 percent of the students and breakfast program rules also require in the lunch program also participate in lower sodium levels; the changes are the breakfast program.124,125 being phased in over several years.130,131 Nearly all schools have successfully The Healthy, Hunger-Free Kids Act implemented these standards.132 of 2010 (HHFKA) required USDA to TFAH • RWJF 29 Research has shown that students receiving free or reduced- price lunch ate more fruits and vegetables than children not participating in the program.133 Research also demonstrates that the healthier lunches are generally liked by students,134 and are popular among parents.135, 136 Recently, several aspects of these new an omnibus spending bill that provided rules have been rolled back. In 2017, $24.3 billion to carry out the majority of USDA published an interim final rule programs authorized under the Child covering the 2018-2019 school year that Nutrition Act.139 This includes increased permits schools and child-care providers funding for several initiatives: to provide flavored 1 percent milk to l $ 30 million for schools to purchase K-12 schoolchildren and to CACFP and food service equipment to serve Special Milk Program participants ages healthier meals, improve food safety, 6 or older. The rule also permits school or expand breakfast options; meal programs to serve grains other than whole grains and foods with a higher l $ 5 million for the Farm to School sodium content than the phased-in rule Program, doubling current funding; would have required. USDA intends to l $ 2.4 billion in additional CACFP issue a final rule on these provisions in funding, nearly doubling the fall 2018.137 USDA has also proposed a program’s budget for FY 2018 (the rule exempting small school districts largest single-year increase in the from the education and training history of the program). requirements for nutrition directors.138 l $ 2 million for child nutrition While the Administration proposed a programs to train school food-service budget cut in FY 2018, Congress passed personnel.140,141,142 30 TFAH • RWJF iii. Supplemental Nutrition Assistance Program The Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamp Program, is the nation’s largest nutrition-assistance effort, helping to feed about 40 million Americans each month.143 The federal government funds SNAP benefits and splits the cost of administering the program with the states.144 More than 7,000 farmers’ markets and farmers nationwide now accept SNAP benefits.145 SNAP enables low-income families to better afford food, and research has shown that the program increases food security and can be associated with better health outcomes. One study found that SNAP Other studies have suggested that Designed to assist the women with participation reduced the percentage while SNAP reduces hunger, it has reintegration into the community, the of families that were food insecure by as been less successful at improving diet class teaches them how to shop for much as 17 percent,146 while another study quality. In 2013, USDA published nutritious ingredients and prepare found that children participating in SNAP results of the Healthy Incentives Pilot, a healthy meals on a budget.153 were a third less likely to experience food demonstration project that incentivized insecurity.147 A study which examined l t. Margaret’s Center in Los Angeles S fruit and vegetable purchases among long-term effects found that individuals has started a weekly walking club for certain SNAP recipients.150 The whose households had access to food seniors. At the end of each walking research found that an ongoing stamps during early childhood had better session, program leaders provide investment of less than 15 cents per health outcomes than those who lived in participants with chilled water and person per day may result in a 25 counties without the program, including healthy snacks and invite them to percent increase in fruit and vegetable significantly lower rates of obesity, attend a nutrition class.154 consumption among adults. high blood pressure, and diabetes (the l The Rockland, Maine Farmers’ food stamp program was not available SNAP-Ed, the educational component Market created the “Kids Club” in universally at the very beginning and this to the program, encourages participants 2016, an interactive summer nutrition study looks at the differences stemming to make healthy food choices, and education program that introduced from kids at that time period).148 emphasizes obesity prevention.151 children ages 5-16 to new foods and An evaluation of several SNAP-Ed Despite the benefits, SNAP does not fully local farmers. The Rockland Farmers’ nutrition programs found an increase cover participants’ food costs. A recent Market plans on continuing youth in fruit and vegetable consumption analysis by the Urban Institute found that programming and Maine SNAP-Ed among elementary school children and the maximum SNAP benefit provides up is working to replicate the Kids Club seniors in the program.152 Examples of to $1.86 per meal, although the average model statewide.155 innovative SNAP-Ed programs include: cost of a meal in low-income households The FY 2018 omnibus spending is $2.36. Because SNAP does not take into l The Arkansas Hunger Relief Alliance bill funded SNAP at $74 billion, a account geographic differences in food recently partnered with the Arkansas reduction of $4.5 billion from the prices, the average cost of a low-income Department of Corrections on a program’s FY 2017 level.156 The bill meal in the most expensive areas of the nutrition education pilot program increased discretionary funding for country is between 68 and 136 percent for female inmates nearing the SNAP-Ed to $421 million from $411 higher than the per-meal SNAP benefit.149 completion of their sentences. million in FY 2017.157,158 TFAH • RWJF 31 iv. Food Insecurity Nutrition Incentive Program Policies can also promote healthy on fruits and vegetables earns them a choices by lowering the cost of nutritious coupon good for 50 percent off their foods. USDA’s Food Insecurity Nutrition next fresh produce purchase.162 Another Incentive (FINI) program incentivizes FINI grantee, Michigan’s Fair Food SNAP participants to buy more fresh Network, started the Double Up Food produce. Created under the 2014 Farm Bucks program at a handful of sites in Bill, FINI is jointly administered by FNS Detroit in 2009. The program allows and the USDA’s National Institute of participants to spend double the value Food and Agriculture.159 In 2017, USDA of SNAP benefits when buying fruit and provided $16.8 million in awards to vegetables, and has since expanded to 32 FINI grantees.160 The program was 250 stores across Michigan—and to 25 expanded for FY 2018 to provide $21 other states as well.163 A five year study million in grant funding.161 of the Double Food Bucks statewide program in Michigan found that more FINI grantees use multiple strategies than 90 percent of participants at to encourage SNAP participants to farmers’ markets reported eating more buy more fruits and vegetables. For fruits and vegetables and more than example, the AARP Foundation uses its 80 percent reported buying fewer low- FINI grant to support its Fre$h Savings nutrition snacks.164 These incentive program at participating farmers’ programs help to support the bottom markets and Kroger stores in Mississippi lines of participating retailers while and Tennessee. With Fre$h Savings, improving health.165 every $10 spent by SNAP recipients B. NUTRITION INFORMATION AND EDUCATION Survey research shows that Americans’ i. Dietary Guidelines general confusion about nutrition Every five years, USDA and the may contribute to the obesity crisis.166 Department of Health and Human In addition to the educational Services (HHS) jointly publish the components of the nutrition- Dietary Guidelines for Americans to assistance programs discussed above, reflect the latest nutrition science. The the federal government also provides 2015–2020 Guidelines focus on how nutrition information via the Dietary Americans ages 2 or older can achieve Guidelines for Americans, considered an overall healthy eating pattern.169 The the gold standard of healthy eating, Guidelines explicitly detail or inform and via nutrition information the nutritional basis for a multitude required on packaged foods and in of federal and non-federal nutrition chain restaurants.167,168 assistance programs and practices, including the school breakfast and lunch programs. The 2020–2025 guidelines, will, for the first time, include standards for pregnant women, infants, and toddlers.170 32 TFAH • RWJF ii. Nutrition Labels Since passage of the Nutrition Labeling servings” more prominent, adding and Education Act of 1990, FDA has a new “added sugars” reporting required nutrition labels on most requirement, and adjusting the packaged foods and beverages.171 In serving sizes to more accurately reflect 2016, FDA finalized comprehensive Americans’ current dietary habits.172 changes to the label requirements The FDA recently extended the to better reflect the latest scientific compliance date to January 1, 2020 knowledge about healthy eating. These for large manufacturers and January changes included increasing the text 1, 2021, for smaller manufacturers.173 size of the nutrition information panel Thousands of products already use the to make “calories” and “number of new label voluntarily.174 Nutrition Facts Serving Size 2/3 cup (55g) Nutrition Facts Servings Per Container About 8 8 servings per container Serving size 2/3 cup (55g) Amount Per Serving Calories 230 Calories from Fat 72 Amount per serving Total Fat 8g % Daily Value* 12 % Calories 230 % Daily Value* Saturated Fat 1g 5% Trans Fat 0g Total Fat 8g 10% Cholesterol 0mg 0% Saturated Fat 1g 5% Sodium 160mg 7% Trans Fat 0g Total Carbohydrate 37g 12 % Cholesterol 0mg 0% Dietary Fiber 4g 16 % Sodium 160mg 7% Sugars 12g Total Carbohydrate 37g 13% Protein 3g Dietary Fiber 4g 14% Total Sugars 12g Vitamin A 10% Includes 10g Added Sugars 20% Vitamin C 8% Protein 3g Calcium 20% Iron 45% Vitamin D 2mcg 10% * Percent Daily Values are based on a 2,000 calorie diet. Your daily value may be higher or lower depending on Calcium 260mg 20% your calorie needs. Calories: 2,000 2,500 Iron 8mg 45% Total Fat Less than 65g 80g Sat Fat Less than 20g 25g Potassium 235mg 6% Cholesterol Less than 300mg 300mg Sodium Less than 2,400mg 2,400mg * The % Daily Value (DV) tells you how much a nutrient in Total Carbohydrate 300g 375g a serving of food contributes to a daily diet. 2,000 calories Dietary Fiber 25g 30g a day is used for general nutrition advice. Source; FDA TFAH • RWJF 33 iii. Menu Labeling To help consumers make informed consumers, who are eating more food choices, the Affordable Care Act away from home.178 Food outside the requires chain restaurants, other home tends to have more calories,179 food retailers, and vending machine yet consumers tend to underestimate companies to provide nutritional the number of calories and sodium in information about their products.175 those meals.180,181 Implementation of these requirements Several studies show that posting was delayed for several years until they nutritional information at the point took effect in May 2018. Under the of purchase can result in healthier rules, chain restaurants with 20 or more choices.182,183,184,185 In addition, there is locations must prominently display evidence that menu labeling may lead calorie counts on menus and menu restaurants and others to reformulate boards.176 The vending machine rule the nutritional content of their food went into effect in 2016, but for some to make it healthier.186 Some studies products sold in glass-front vending have found significant results at specific machines, the rule was delayed until July establishments or among specific 2018.177 populations,187,188 but others have found Menu labeling is designed to provide no changes in consumer behavior from nutrition information directly to menu labeling.189 34 TFAH • RWJF Children are exposed to an average of 10 to 11 television ads for food each day—and most of those ads are for unhealthy products, such as fast food, candy, and sugary drinks.192 vi. Food and Beverage Marketing Research has demonstrated a strong quality.201,202 That’s because some food association between food and beverage and beverage companies, through marketing and childhood obesity the Children’s Food and Beverage rates.190 One study found that even Advertising Initiative, have voluntarily one advertisement can influence a pledged to adhere to nutrition person’s product preference and standards and to limit food advertising that preferences are continually to children under age 12.203,204 strengthened by repeated exposure.191 Studies have found, however, that A 2017 study found that children are self-regulation still falls short.205 First, exposed to an average of 10 to 11 the industry only pledged to limit television ads for food each day—and advertising that is “primarily directed” most of those ads are for unhealthy to children.206,207 This definition products, such as fast food, candy, captures only about half of the food and sugary drinks.192 Another 2017 and beverage television ads viewed by study found a link between fast-food children, and it still permits marketing advertising and consumption among to a general audience on the websites preschoolers, with even moderate and social media platforms that millions exposure increasing consumption of children use.208,209 Second, while many by 31 percent.193 Black and Latino products marketed to kids meet the youth are exposed to an even greater industry’s nutrition standards, they fail amount of unhealthy food marketing more stringent standards set by experts than White youth.194,195 Children are in nutrition policy.210,211 Third, industry exposed to these ads while watching pledges place no limits on marketing to television, playing video games,196 children over the age of 11.212 Finally, watching YouTube videos,197 interacting a number of large food and restaurant on social media platforms,198 watching companies that market to children their favorite sports teams,199 and while have not joined these industry efforts. grocery shopping.200 In fact, a small number of companies In recent years, there have been fewer have actually increased their food and food ads on children’s television, and beverage advertising on children’s the products advertised have made programming in recent years, partly modest improvements in nutritional offsetting any reductions.213 TFAH • RWJF 35 C. CHILD CARE AND EDUCATION REQUIREMENTS Childhood is a critical time for obesity obesity, encouraging healthier diets, Research demonstrates that prevention. It is much easier to avoid and fostering more physical activity.215 obesity in the first place—by establishing A recent study modeling impact comprehensive school programs lifelong habits of healthy eating and and cost-effectiveness of six physical are effective in preventing regular exercise—than it is to lose excess activity-increasing interventions in childhood obesity, encouraging weight later in life. One recent study school and afterschool settings found found that Finnish children ages 3 to 5 that all the interventions assessed healthier diets, and fostering with a high BMI were more than three would increase youth physical activity more physical activity.215 times as likely to have obesity as adults.214 levels and be either cost-saving or cost-effective, ultimately preventing Research demonstrates that between 2,500 and 110,000 cases of comprehensive school programs are children with obesity.216 effective in preventing childhood i. Early Child Care and Education Head Start Head Start and Early Head Start Programs must meet nutritional and are federally funded programs that physical activity standards set by the promote school readiness for young Administration for Children and children from low-income families by Families. In 2016, updated regulations providing education, health, and social went into effect, the first major rewrite services.217 The programs served more since the 1970s.219 The revised standards than 1 million children and pregnant require Head Start programs to actively women during the 2016–2017 program engage in obesity prevention both in year.218 The federal government the classroom and through its family- provides funding and oversight to local partnership process.220 In addition to agencies that administer the programs. these direct changes to nutrition and Head Start and Early Head Start physical activity practices, Head Start programs participate in either CACFP as a whole has been shown to improve or the National School Lunch Program. health outcomes in young adulthood.221 36 TFAH • RWJF States’ Early Child Care and this program has reached 15 states Education Requirements (Alabama, Arizona, Arkansas, California, Facilities that provide early care and Florida, Illinois, Indiana, Kansas, education are largely regulated on the Kentucky, Missouri, New Jersey, Ohio, state level. Because most preschool-aged Tennessee, Virginia and Wyoming) and American children spend time in care directly trained ECE providers from outside their home,222,223 state obesity- 2,300 programs, serving more than prevention requirements for early child- 194,000 children. ECE providers in the care and education (ECE) providers can learning collaborative have shown a help ensure millions of young children statistically significant increase in the are eating healthy foods and getting adoption of best practices for healthy plenty of time for active play. eating, physical activity, reduced screen time, and breastfeeding support.226 The CDC offers a framework to assess states’ ECE obesity-prevention efforts. In CDC also partnered with the Association its 2016 evaluation of states’ success, the of State Public Health Nutritionists to CDC reported: help states implement evidence-based, system-level approaches to prevent l 7 5 percent of states with Quality obesity among children ages 2 to 5. This Rating and Improvement Systems Pediatric Obesity Mini-Collaborative standards for their ECE providers Improvement and Innovation Network include obesity-prevention standards. includes 13 states (Arkansas, California, l 2 5 states improved the obesity Indiana, Iowa, Kentucky, Louisiana, standards in their ECE licensing Missouri, North Dakota, Ohio, regulations between 2011 and 2014. Oklahoma, Oregon, Pennsylvania, and Wisconsin).227 l 2 9 states encourage enhanced nutritional standards in their CACFP Other CDC grant recipients have more program. expansive initiatives. Through the State Public Health Actions program, CDC l 4 2 states offer online professional devel- has provided funding, training and opment training to ECE providers.224 technical assistance to all states and DC since 2013 to strengthen nutrition and CDC ECE Initiatives physical activity standards and practices Several CDC grant programs, like in their ECE settings. For example, the Early Childcare and Education in North Dakota, it helps 25 child- Learning Collaborative, provide training care centers to improve nutrition and and technical assistance to states to increase physical activity.228 Similarly, help them with obesity prevention through the High Obesity Program in ECE settings. CDC–in partnership (described in more detail on page 42). with Nemours Health System and the West Virginia University trains ECE Association of State Public Health providers to improve the nutrition and Nutritionists—works with state public physical activity at their facilities and to health and ECE leaders to: 1) improve engage families in healthier lifestyles.229 state ECE systems, and 2) support In FY 2018, Congress appropriated select ECE providers with training and $4 million for Early Childcare and technical assistance through a learning Education Learning Collaboratives.230 collaborative.225 In the past six years, TFAH • RWJF 37 ii. Elementary and Secondary Education Local School Wellness Policies from the standards, although 21 states CDC Healthy Schools also awarded Given that children spend so much have policies in place allowing zero 17 states with five-year Department of time at school—where they consume up exemptions.237 The snacks standards are Education grants—called Improving to half their daily calories231—school- similar to requirements covering the Student Health and Academic based obesity prevention programs can National School Lunch and Breakfast Achievement through Nutrition, Physical have a large reach and impact. As of Programs. The Smart Snacks in School Activity and the Management of Chronic 2006, school districts that participate rule exempts snacks sold after school Conditions in Schools—to implement and in federal child nutrition programs hours, food intended to be eaten off evaluate obesity prevention and chronic are required to develop a wellness school property, or food provided for disease management initiatives.241 The policy—and these requirements were free—for example, cupcakes brought in award is $355,000-$365,00 per year from expanded with passage of HHFKA.232 for a student’s birthday. 2018 to 2023. Tennessee also will receive The final rule implementing the additional funds to provide professional HHFKA wellness policy requirements CDC School Initiatives development and technical assistance took effect for the 2017–2018 school The CDC assists elementary and on building capacity and evidence-based year.233 Among other requirements, secondary schools with obesity interventions to other states.242 local wellness policies must: prevention efforts through its Healthy The CDC Healthy Schools program Schools program. Some examples of received $15.4 million in funding for l E stablish nutrition promotion and CDC resources include: FY 2018.243 physical activity goals. l irtual Healthy School is an online tool V State Public Health Actions program, l I nclude nutrition guidelines for foods that allows school administrators and mentioned in the ECE section earlier, available on campus. policymakers to see policies that can supported obesity prevention efforts l L imit food marketing to those improve student health in action. These in elementary and secondary schools products that meet the Smart include a virtual cafeteria offering between 2012 and 2017: Snacks in School nutrition standards healthy food choices and a virtual (discussed in more detail below). playground that promotes physical l O regon spent its CDC State Public activity. Virtual Healthy School is part Health funding to create a dedicated Despite the new requirements, a review staff position to coordinate school of the CDC’s Whole School, Whole of school district wellness policies found district wellness efforts.244 Community, Whole Child model.238 that only 57 percent of policies included all federally required topics.234 Interested l chool Health Guidelines to Promote S l N ew Hampshire used its funding to states and school districts can make Healthy Eating and Physical Activity improve the nutrition of the food served adherence to wellness policies part of synthesizes the latest obesity-prevention in its schools, including by adding more their state or local report card measures research and provides guidelines to help attractive serving bowls for fruits and under the Every Student Succeeds Act.235 schools encourage their students to eat vegetables, using less packaged food, healthily and be physically active.239 and cooking healthier foods from Smart Snacks in Schools scratch—such as soups and smoothies.245 l chool Health Index: Self-Assessment S Since September 2016, all food sold and Planning Guide 2017 allows l O hio’s Cloverleaf School District at schools—including food sold in schools to conduct a self-assessment of used the funding to improve its vending machines, at school stores, their health and safety policies and to nutrition program, which resulted and at school fundraisers—must meet develop an action plan for improving in a 350 percent increase in produce federal nutrition standards.236 States can student health.240 consumption.246 exempt infrequent school fundraisers 38 TFAH • RWJF School-Based Physical Activity and personnel on how to integrate physical Elementary school recess requirements Physical Education Programs activity breaks or nutrition education are set at the state level.257,258 In 2017, Physical Education into the classroom. the Council of State Governments Physical education (PE) provides reported that only four states— l A llows schools to integrate PE-related important benefits for children, and Connecticut, Missouri, Rhode Island, measures—such as PE class size, research has demonstrated the cost- and Virginia—required daily recess minutes of PE offered by grade, or effectiveness of school-based physical for elementary school students,259 and minutes of physical activity—into their activity programs and their efficacy in Indiana required daily physical activity, state report cards. preventing childhood obesity.247,248 which can include recess.260 Since then, l R equires that PE or physical activity at least two more states, Arizona and Despite the documented benefits of PE, programs be used as indicators of school Florida, have passed laws requiring daily there are no federal PE requirements, quality in school accountability plans. recess. not all states require students to participate in PE, and few states CDC, in collaboration with SHAPE In 2017, CDC and SHAPE America require a minimum number of PE America, developed the Comprehensive published Strategies for Recess in minutes per week. Only Oregon and School Physical Activity Program to Schools, created in collaboration Washington, D.C. require schools to encourage schools and school districts with other national organizations, meet the national standards for physical to implement a variety of approaches to recommending 20 minutes or more education at both the elementary help students get their recommended of recess daily for elementary students and middle-school levels.249 Even 60 minutes or more of physical activity and recommending a period of daily where state requirements are in place, daily and to develop the knowledge and physical activity for middle and high however, schools are not necessarily in skills to be physically active throughout school students in addition to physical compliance. A 2016 Washington Post their lives.253 The Comprehensive education and classroom physical investigation found that only 10 of School Physical Activity Program enables activity.261 the more than 200 public and charter schools to coordinate and align PE Physical Activity Guidelines schools in Washington, D.C. were programs with physical activity before, In 2008, HHS released Physical Activity meeting the law’s PE requirements.250 during, and after school. Guidelines to provide policymakers Some states are loosening their PE Recess and health professionals guidance requirements. In December 2017, Research demonstrates that children on physical activity that provides Chicago Tribune reported that a recent benefit in numerous ways from having a substantial health benefit. The change in Illinois law had “gutted” the time for physically active free play guidelines recommend the duration state’s PE rules. Once required daily, during the school day.254 The American and kinds of activities for different PE is only required three days per week Academy of Pediatrics (AAP) describes groups of Americans (e.g., children/ under the new law.251 recess as “a crucial and necessary adolescents, adults, older adults, women The Every Students Succeeds Act component of a child’s development” who are pregnant/postpartum, adults (ESSA) provides opportunities to and explains that “recess is unique with disabilities). For children and promote PE:252 ESSA: from, and a complement to, physical adolescents, the guidelines recommend education—not a substitute for one hour or more of physical activity l E xpands the federal definition of a it.”255 AAP specifically credits recess daily, including aerobic (vigorous well-rounded education to include with helping students meet their intensity), muscle-strengthening, and physical education. recommended 60 minutes of daily bone-strengthening activities three l P ermits federal funding for training physical activity, which in turn lowers times a week each.262 HHS is expected to classroom teachers and other school rates of obesity.256 release revised guidelines in late 2018. TFAH • RWJF 39 D. COMMUNITY POLICIES AND PROGRAMS Recent evidence highlights the healthy options, reducing deterrents importance of comprehensive, to healthy behaviors, improving social community-wide efforts to address and economic resources, and building nutrition and physical activity beyond community capacity—to consider with school and child care settings. The respect to obesity prevention policies Healthy Communities Study, which and programs.264 Additionally, the CDC’s included more than 5,000 children from Practitioner’s Guide for Advancing more than 1,000 communities, found Health Equity identifies evidence-based that areas with policies and programs that and promising strategies for improving targeted more kinds of healthy behaviors health equity at the policy, systems, and related to physical activity and nutrition environmental levels.265 were associated with lower BMI and Examples of community policies and smaller waist circumference in children.263 programs that employ a comprehensive The 2017 Equity-Oriented Obesity approach to addressing obesity and Prevention Action Framework includes related disparities are described below. four categories of initiatives—increasing i. Community Design and Land Use Research has found a link between built community design and land-use can environments—all the human-made encourage physical activity by providing physical aspects of a community—and safe and accessible sidewalks; investing both physical activity and obesity. The in biking infrastructure, parks, and odds of a child having obesity or being public transportation; and breaking overweight increase by 20 to 60 percent down barriers to active commuting. if he or she lives in a neighborhood with In April 2018, the U.S. Department unfavorable environmental aspects, such of Transportation announced the as poor housing, unsafe conditions, availability of $1.5 billion in funding for and no access to sidewalks, parks, Better Utilizing Investments to Leverage or recreation centers.266 Thoughtful 40 TFAH • RWJF Development (BUILD) grants. The schoolyards into community spaces for BUILD grants replace the department’s physical activity and community vegetable Transportation Investment Generating gardens. By using green landscaping Economic Recovery (TIGER) grant techniques, the city saves money on program. Eligible grantees can apply for reduced water usage and flooding. A pilot up to $25 million in funding to support study of the initiative found increases in roads, bridges, transit, rail, and other physical activity among students.272 forms of intermodal transportation, including biking and walking trails. ii. Safe Routes to School Communities can use many strategies to Walking or biking to school is an easy promote physical activity: way for children to get more exercise: walking one mile to and from school l Z oning policies can encourage mixed- each day provides a child with two-thirds use neighborhoods, places where of the recommended 60 minutes of work sites, residences, and commercial daily physical activity.273 A 2016 survey of areas are all within walking distance 6,500 schools found that walking to and of each other. Residents of mixed-use from school increased from less than neighborhoods are 33 percent more 14 percent to more than 17 percent likely to meet physical activity guidelines of all school trips between 2007 and by walking for transportation.267 2014.274 Safe Routes to School (SRTS) l B uilding sidewalks and installing initiatives promote walking and biking crosswalks, crossing signals, pedestrian to school by educating students and signs, street lights, and features to reduce families about the benefits and ensuring vehicle speed can improve conditions for that the school environment allows walking. People in neighborhoods with kids to do so safely. To implement an sidewalks are 50 percent more likely to SRTS initiative, states, localities, and meet the recommended daily amount of school districts can compete for federal physical activity.268 funding, which is available through funding set aside for transportation l A dding protected bike lanes, building alternatives under the Fixing America’s bike paths, installing bike racks, and Surface Transportation Act.275 sponsoring bike-sharing services can create a safe bike environment. SRTS programs have resulted in Installing a traffic-free bike route can statistically significant improvements increase time spent cycling,269 and in active transportation to school. One residents of neighborhoods where a study of 800 schools (in four states) higher percentage of people bike to with SRTS programs found that rates of work have lower BMIs.270 walking and biking to school increased after the program started—and could l E xpanding and investing in public even lead to a 25 percent increase over transportation is important because five years in walking and bicycling.276 using public transportation can result in eight to 33 minutes of additional In 2018, the Safe Routes to School National walking per day.271 Partnership issued a report card assessing states on how well they support walking, One example of intentional community biking, active kids, and active communities. design is from the Chicago-based Safe Only two states—California and Space to Grow initiative. This initiative Washington—received the top grade.277 reimagines and converts underused TFAH • RWJF 41 iii. CDC Community Initiatives The CDC funds community-based obesity l H elping 18 worksites in South Dakota prevention initiatives around the nation. make improvements to encourage A recent study of CDC obesity-related physical activity, benefiting 2,800 health promotion and intervention employees;281 and programs from 2000 to 2010 found that l E ducating community leaders in 21 states using these programs had reduced cities, two counties, and one tribe in odds of obesity in adults.278 This year, Washington state about better street there are several major changes to the design, which can improve safety and grants that CDC is offering. The State encourage physical activity.282 Public Health Actions program—which provided funding to all 50 states and the High Obesity Program—CDC- District of Columbia— ended June 20, RFA-DP18-1809 2018. It is being replaced with the State Physical Activity and Nutrition (SPAN) This program funds land-grant colleges program, which will provide funding to 15 and universities in states with counties states and begin on September 30, 2018. where the obesity rate exceeds 40 percent There is also a proposed increase in the to conduct community and county level number High Obesity Program awards. interventions.283 Since 2014, the program has funded programs in 11 states. State Physical Activity and Nutrition l T he University of Georgia is working Program (SPAN)—CDC-RFA-DP18-1807 with Calhoun and Taliaferro counties In April 2018, the CDC announced the to establish community gardens to help availability of FY 2018 funds for SPAN. stock food pantries, and it is promoting SPAN grants replace the State Public activities such as bike rodeos and Health Action (1305 funding) grants, exercise sessions for seniors.284 moving from lower levels of funding to l T exas A&M University is enhancing grantees in all states to higher funding in parks and sidewalks for physical activity a subset of grantees. SPAN will support and promoting healthier food in retail five-year projects that invest in statewide establishments in Hidalgo County.285 efforts to improve nutrition or increase physical activity. CDC plans to support l N orth Carolina State University helped approximately 15 projects with an average develop a community garden that now annual award of $900,000.279 produces 500 pounds of produce for low-income families and housebound In the past, State Public Health Action adults in Roanoke Rapids.286 (1305 funding) has supported efforts like: The FY 2018 omnibus spending bill l I mproving access to affordable fruits funded this program at $15 million, and vegetables to hundreds of Michigan a $5 million increase over FY 2017.287 families through the Quality Dairy CDC plans on supporting 14 land grant convenience store program;280 universities for the 2018-2023 grant cycle. 42 TFAH • RWJF Preventive Health and Health l P rovided fruit and vegetable vouchers to Services (PHHS) Block Grant Navajo families in New Mexico who have This program provides states with limited access to healthy foods;298 and flexible support to address important l P romoted the benefits of biking to health needs.288 In FY 2017, states the nearly 60,000 residents of Pontiac, spent approximately 6 percent of total Michigan, and installed 38 bike racks PHHS funding on healthy weight and across the city.299 nutrition efforts.289 FY 2018 funding for the REACH PHHS funding has supported community- program remained level at $51 based obesity-prevention activities: million, with $35 million provided l F airfield, Connecticut, created its first for a supplemental year of the three- official bike route.290 year cooperative agreement for community programs and $16 million l 2 4 Florida hospitals promoted for Good Health and Wellness in breastfeeding.291 Indian Country.300, 301 l L ouisiana helped 93 organizations design employee wellness programs.292 Childhood Obesity Research Demonstrations (CORD 2.0) Fourteen states and territories made The second funding period (2016– reducing obesity an objective they 2018) of this research project focuses targeted with their PHHS funding in FY on weight-management interventions 2017: Alaska, California, Guam, Kansas, for children in low-income families Nevada, New Jersey, New Mexico, who are struggling with obesity in Pennsylvania, Puerto Rico, South Massachusetts and Arizona. It focuses Dakota, Tennessee, Utah, Vermont, and on the role of healthcare providers Wisconsin.293 Funding for the PHHS and community partners, such as Block Grant remained level in FY 2018 the YMCA. The project uses BMI at $160 million.294, 295 screening, nutrition and physical activity counseling, and healthy Racial and Ethnic Approaches to weight programs to help address Community Health (REACH)—CDC- obesity in young people.302 Previously, RFA-DP18-1813 CORD included three multi-sector A national program to reduce health interventions, including a 12 month disparities, REACH provides funds program in Texas consisting of three to community organizations, tribes, months of an intensive intervention universities, and state and local health followed by a nine month transition departments to implement culturally phase at a lower intensity. The appropriate programs, including children enrolled in the program had obesity-prevention efforts, among significantly lower weights at three African Americans, American Indians, months compared with those not in Latinos, Asian Americans, Alaskan the program—but the children did Natives, and Pacific Islanders.296 not maintain the weight loss after the REACH-funded projects have: full year.303 l E ducated more than 14,000 Latinos in Maryland about the benefits of drinking water instead of sugary beverages;297 TFAH • RWJF 43 National Diabetes Prevention Program 1. Delivering physical activity Congress authorized the CDC to establish programs proven to work; this program, a public-private partnership 2. Mobilizing partners to work on supporting evidence-based type 2 diabetes physical activity efforts; prevention interventions in communities 3. Sharing messages that promote around the country. The program works active lifestyles; to prevent or delay a diagnosis of type 4. Training leaders who will promote 2 diabetes for the 86 million Americans physical activity; and with prediabetes.304 The omnibus bill funded the National Diabetes Prevention 5. eveloping technologies, tools, and D Program at $25.3 million for FY data to collect accurate information 2018.305 As of April 2018, Medicare will about Americans’ physical activity.306 reimburse the program for patients with The 2018 omnibus spending bill prediabetes. The decision to pay for this provided $800 million in funding for service offers the promise of expanding the Prevention and Public Health Fund access to this evidence-based program to and $915 million for Chronic Disease millions of people. Additional information Prevention and Health Promotion, on this program is on page 49. including $54.9 million for nutrition, The CDC also works to increase physical activity, and obesity.307,308 Americans’ physical activity through its Active People, Healthy Nation initiative, which has five steps: SELECT OBESITY-RELATED FUNDING OPPORTUNITIES FROM CDC Number of Available Estimated Grant/ Program Name Grant Goal Length of Grant Annual Grant Size Grants Total Funding State Physical Activity Improve nutrition or increase 5 years starting in 15 states $900,000 average $70 million Nutrition Program (1807) physical activity September 2018 High Obesity Program Reduce obesity in areas with 5 years starting in 14 projects at land- $800,000 average $56 million (1809) obesity rates over 40 percent September 2018 grant universities 50 states, D.C, 2 Preventive Health and Provide each state with flexible American Indian Tribes, $160 million Health Services Block support to address its most Annual n/a and 8 U.S Territories (FY 2018) Grant important health needs (61 total) Racial and Ethnic Reduce health disparities within 5 years starting in $125.5 Approaches to Community minority communities through 32 projects $780,000 average September 2018 million Health (1813) culturally appropriate programs Improving Student Increase number of students Health and Academic who eat nutritious food/ 17 states (AK, AZ, AR, Achievement through beverages, participate in 5 years starting in CO, IL, KY, LA, MA, MN, Nutrition, Physical Activity $400,000 average $35 million daily physical activity, and can June 2018 MO, NE, NM, NC, OK, and the Management effectively manage their chronic OR, TN, WA) of Chronic Conditions in health conditions Schools (1801) Source: CDC 44 TFAH • RWJF E. FISCAL POLICIES TO PROMOTE NUTRITION Fiscal incentives can affect food choices, percent reduction in the cost of healthy obesity levels and resultant disease and foods increased their purchase by 16 Every 10 percent price increase death rates. Current agricultural subsidies percent.311 Researchers recently modeled on unhealthy food reduced sales focus on financing the production of the potential effects of price subsidies commodities (corn, soybeans, wheat, (on fruits, vegetables, whole grains, and by 6 percent, while a 10 percent rice, sorghum, dairy, and livestock) that nuts/seeds) and taxes (on processed reduction in the cost of healthy are often converted into high-fat meat meat, unprocessed red meats, and sugar and dairy products, refined grains, corn sweetened beverages), and found that, foods increased their purchase sweeteners, and processed and packaged together, they could prevent more than by 16 percent. foods. Between 1995 and 2010, $170 billion 20,000 such deaths per year and might was spent on these seven commodities reduce disparities between those with and programs.309 Higher consumption differing levels of education as well.312 of calories from these subsidized foods In addition to taxes and subsidies, has in turn been associated with greater there are also federal programs that probability of high BMI, high cholesterol, financially incentivize development and other obesity-related risks.310 that increases access to healthy food or A 2017 review of 30 studies measuring the physical activity opportunities. effect of food pricing found that every 10 A few fiscal policies to this effect are percent price increase on unhealthy food highlighted below. reduced sales by 6 percent, while a 10 i. ealthy Food Financing Initiative H More than 23 million Americans— provides financial and technical including 6.5 million children—live assistance to food retailers to increase in a food desert. The Healthy Food the availability of local foods and to Financing Initiative—a joint effort of help encourage demand for healthy HHS, USDA, and the U.S. Treasury foods. The Treasury Department’s Department along with private Community Development Financial businesses—helps establish and equip Institutions Fund provides financing grocery stores in communities that and technical assistance to institutions lack access to affordable, healthy food. that invest in businesses that sell healthy HHS awards competitive Community foods.313 Between 2011 and 2015, the Economic Development grants that Healthy Food Financing Initiative both help reduce food deserts and established or supported more than stimulate job and business development 1,000 grocery stores and healthy food in low-income communities. USDA businesses across 35 states.314 TFAH • RWJF 45 ii. New Markets Tax Credit The New Markets Tax Credit encourages barriers to a healthy lifestyle that exist investment in low-income communities.315 in low-income communities. Since By incentivizing companies to build 2003, the New Markets Tax Credit has projects such as supermarkets or supported more than 4,800 projects in fitness facilities in communities that every state, the District of Columbia, lack access to affordable, healthy foods and Puerto Rico, including $42 billion and safe places to play and exercise, in direct investments to low-income this program is removing some of the communities.316,317 iii. Beverage Taxes Providing consumers with financial over a decade, prevent more than half incentives to make healthier food a million cases of childhood obesity. It choices has proved to be effective.318 would also save the United States more According to a model developed by the than $14 billion, mainly from reduced Childhood Obesity Intervention Cost- medical costs. Another CHOICES study Effectiveness Study (CHOICES) at the modeled sugary drink taxes in 15 large Harvard T.H. Chan School of Public cities, estimating the tax would prevent Health, a nationwide sugar-sweetened 115,000 cases of obesity and save more beverage tax of 1 cent per ounce would, than $750 million over a decade.319 ESTIMATED EFFECT OF SUGARY DRINK TAX ($0.01 PER OUNCE) ON SELECT CITIES OVER 10 YEARS Health Care Cost Cases of Obesity Deaths City Net Savings Savings per $1 Prevented Averted Invested Baltimore 4,950 131 $31.6 million $31.70 Charlotte 7,140 154 $33.6 million $30.60 Columbus 7,690 154 $46.3 million $37.80 Denver 5,120 93 $35.3 million $36.40 Detroit 7,200 187 $33.6 million $29.50 Indianapolis 7,710 174 $43.3 million $36.80 Jacksonville 7,300 173 $39.6 million $34.84 Las Vegas 4,678 95 $23.1 million $26.30 Los Angeles 21,700 374 $177 million $28.20 Louisville 6,793 181 $41.3 million $52.10 Oklahoma City 4,590 110 $20.0 million $24.80 Phoenix 13,510 221 $79.8 million $35.80 San Diego 7,100 126 $58.3 million $27.20 San Jose 5,200 93 $43.4 million $27.50 Seattle 3,990 83 $52.8 million $86.90 Source: Childhood Obesity Intervention Cost-Effectiveness Study 46 TFAH • RWJF Local sugary drink taxes have shown early promise. Berkeley, California, implemented a 1-cent-per-ounce tax on sugary drinks in 2015. Four months after implementation, consumption of these beverages in low-income Berkeley neighborhoods had decreased by 21 percent, while water consumption had increased by 63 percent.320 Another study looking at purchase data in Berkeley found that in the first year, the city had a 10 percent decrease in sugary drink sales and a 16 percent increase in water sales.321 A recent study found that, in the first two months after Philadelphia’s 1.5-cents-per-ounce sugary beverages tax went into effect l A lbany, California—a city of 19,000 in 2017, residents were 40 percent less residents in the greater Bay area— likely to drink regular soda and 58 implemented a 1-cent-per-ounce percent more likely to drink bottled tax on April 1, 2017.327 In the first water daily, compared with residents nine months, the SSB tax raised of nearby jurisdictions.322 Longer term $205,000, most of which the city used studies are needed to understand to: install hydration stations at parks whether sugary drinks taxes affect and the community center; sponsor overall calorie consumption and weight an education campaign that offered status and how the impacts differ by free exercise, nutrition, and cooking race, socioeconomic status, and gender. classes; and host a community Five other municipalities have also walking challenge.328 enacted sugary drink taxes, including l I n Seattle, a tax on distributors of sugary Boulder, Colorado (2 cents per ounce); drinks at 1.75 cents per ounce went into Seattle, Washington (1.75 cents per effect on January 1, 2018. It will raise ounce); and three additional cities in an estimated $15 million annually— California: San Francisco, Oakland, and money that is earmarked for improving Albany (1 cent per ounce each).323,324,325 access to healthy foods, supporting In a more comprehensive 2015 effort, early childhood programs, and the Navajo Nation added a 2-cents-per- addressing equity in K–12 education. dollar sales tax on all food and beverages In anticipation of 2018 revenue, Seattle with “minimal-to-no nutritional value”; allocated $3.8 million for healthy food it also eliminated all sales taxes on fresh access programs and food banks, $3.3 fruits and vegetables.326 million for early learning services, $2.6 In some cases, cities with taxes on sugary million for educational support and drinks have directed the revenue toward mentoring programs for high school programs that promote healthy eating students, and $2.8 million for additional and active living. For example: community-based programs.329 TFAH • RWJF 47 F. OBESITY PREVENTION IN THE MILITARY The number of active-duty Obesity threatens America’s military with obesity are more likely to be service members who are readiness and national security.330 The injured,332 and the Defense Department overweight or who have number of active-duty service members spends about $1.5 billion each year on who are overweight or who have obesity obesity-related costs, including medical obesity increased by 61 increased by 61 percent between 2002 care for service members and their percent between 2002 and 2011, threatening the military’s families and the cost of replacing unfit and 2011, threatening the ability to deploy.331 Service members service members.333 military’s ability to deploy. i. Military Initiatives Operation Live Well is the Department campaign that promotes four healthy of Defense’s overarching prevention behaviors children should do each day: initiative to promote health, well- 1. Eat 5 or more servings of fruit and being, and readiness among service vegetables. members and in military communities. 2. Spend 2 or fewer hours on a screen. Operation Live Well includes an educational and outreach campaign 3. ngage in 1 or more hours of E as well as demonstration projects, such physical activity. as the Healthy Base Initiative, which 4. Drink 0 sweetened beverages.337 has brought healthy living initiatives to The 5210 campaign has been used on service members and their families on Air Force bases in Idaho, Colorado, 14 pilot installations since 2014.334 In a Oklahoma, Illinois, South Carolina, and survey of more than 600 employees at Florida,338 and the message has been one of the Healthy Base Initiative sites, promoted throughout the military.339 93 percent said the initiative helped change their behaviors, including their In addition, each branch of the armed eating habits and physical activity; 83 services has enacted its own wellness percent used the program’s farmers’ program: market; and 65 percent participated l T he Air Force’s Commanders in its stairwells program.335 The Wellness Program works to improve Department of Defense plans to healthy behaviors and improve expand the most successful programs airmen’s readiness. department-wide. l ealthy Army Communities is a pilot H Also, across all of the branches, military program to transform installations base and facility planning/design is into healthy living communities guided by the Unified Facilities Criteria that emphasize good nutrition and (UFC), which encourages designs physical activity. that promote walking running, and biking, as well as the incorporation of l T he Navy and Marine Corps Public community gardens.336 Health Center is workplace health- promotion program that provides Another military obesity-prevention annual health assessments to sailors effort is 5210 Healthy Military Children, and marines.340 a military-wide public education 48 TFAH • RWJF G. HEALTHCARE COVERAGE AND PROGRAMS The healthcare sector assumes many obesity-related illness rose 29 percent of the direct costs of obesity but also between 2001 and 2015 (from 6.1 to 7.9 plays a vital role within a comprehensive percent).342At the same time, clinical community-wide effort to reduce interventions can help individuals obesity. The estimated annual achieve a healthier weight.343 Healthcare healthcare costs of obesity-related coverage companies and healthcare illness are $190 billion—or nearly 21 systems, with budgets in the billions, percent of annual medical spending can also use their influence with their in the United States.341 A recent study patients and communities to boost found that the percentage of U.S. healthy behaviors and choices at large. healthcare dollars devoted to caring for i. Medicare and Medicaid Obesity imposes high costs on l M edicare Diabetes Prevention cost savings, since Medicare spends Medicare, the federal healthcare Program: One in three American $42 billion per year more on diabetes program for Americans ages 65 adults have prediabetes,352 a condition patients in Medicare Fee for Service and older, and on Medicaid, the where a patient has glucose levels that compared with typical patients.355 Due government healthcare program for are elevated but not high enough for a to the success of the lifestyle program, low-income Americans or those with diagnosis of diabetes. Without changes Medicare began covering MDPP as an disabilities. One study found that severe to their lifestyle, as many as 30 percent additional preventive service with no obesity alone costs state Medicaid of people with prediabetes will go cost for patients on April 1, 2018. This programs almost $8 billion a year.344 on to develop type 2 diabetes.353 The is the first time a prevention model Medicare Diabetes Prevention Program from the Innovation Center (a section Both Medicare and Medicaid cover (MDPP) helps avert the onset of of CMS created by the Affordable Care a variety of obesity-prevention and diabetes among Medicare beneficiaries Act with the mission of developing treatment services. Medicare covers with prediabetes by providing patients new healthcare payment and service BMI screenings and behavioral with practical training on diet, physical delivery models) has expanded counseling for patients with obesity;345 activity, and weight-control strategies. to all qualified beneficiaries.356 it also covers bariatric surgery in some A randomized, controlled clinical Six states—California, Maryland, situations.346,347 States can choose which trial evaluated whether, in people who Montana, Oregon, Pennsylvania, and obesity services to cover for Medicaid are at high risk for type 2 diabetes, Washington—have instituted or are enrollees, and most states cover at least lifestyle programs aimed at helping piloting similar programs.357, 358,359,360,361 one obesity-related service. States vary participants lose a modest amount of widely on the specific services they l C hildhood Obesity Performance body weight could prevent or delay cover and the kind of patients who are Improvement Projects: The federal the disease. This study found that eligible. For children, states have to government mandates that states participants in the lifestyle program cover all medically necessary screening, with a Medicaid managed care reduced their chances of developing diagnostic and treatment services, which program require health plans to diabetes by 58 percent compared with can include obesity services.348,349,350,351 complete performance improvement participants in a control group who did projects (PIPs). Thirteen states Examples of obesity-related CMS not have the lifestyle program.354 reported a combined total of 26 PIPs initiatives related Medicare and In addition to preventing disease, that targeted childhood obesity in Medicaid include: MDPP also has a huge potential for 2014–2015.362 TFAH • RWJF 49 ii. Healthcare Systems and Hospital Programs Healthcare systems and providers can effective obesity-prevention tool,365 play key roles in obesity prevention and and, if applied nationally, could reduction by working with community prevent 43,000 cases of obesity over a partners, implementing evidence- 10-year period.366 based initiatives, and making better connections between clinical and Provider Competencies for the community interventions. Prevention and Management of Obesity Screening Services and Clinical Most healthcare providers receive Decision Support insufficient training in the prevention Healthcare providers can help prevent and management of obesity. To obesity by referring patients with obesity help guide better provider training, to counseling and lifestyle coaching obesity experts from the Integrated programs—a strategy the U.S. Preventive Clinical and Social Systems for the Services Task Force recommends.363 Prevention and Management of Obesity However, successful implementation Innovation Collaborative agreed on 10 of such strategies requires physician core competencies that all healthcare training (such as the American College professionals need to properly care for of Preventive Medicine’s Lifestyle patients. The competencies include Medicine Core Competencies program, a basic knowledge of the disease an evidence-based curriculum for and epidemiology of obesity, an physicians that emphasizes promotion understanding of interprofessional care, of healthy behaviors and environments and a commitment to using best practices and utilizing team care models and for patient interactions and care.367 community resources to deliver care), as well as reimbursement for registered Community Benefit Programs dieticians and other non-physician Most hospitals in the United States providers. Providers can also screen are nonprofit organizations.368 To patients for food insecurity and help qualify for this tax exemption, they connect low-income patients with must demonstrate that their primary nutrition assistance programs such purpose is to benefit the community.369 as SNAP, WIC, and the school meals The Affordable Care Act built on this programs. The American Academy longstanding requirement by mandating of Pediatrics also recommends such that nonprofit hospitals specifically assess, screenings and referrals.364 implement, and evaluate strategies to Providers who use electronic health address their local community’s health records (EHRs) often have access needs.370 Childhood obesity has emerged to clinical decision support systems as a priority health need in many of for assistance in obesity-prevention these hospital assessments. For example, screening and treatment. For example, more than half of the Catholic Health EHRs can be set up to alert clinicians Association’s 203-member hospitals found when patients have a high BMI and childhood obesity to be a top priority for to provide recommendations about their communities,371 while 70 percent counseling resources and weight- of American Association of Medical management programs. This type Colleges’ 238-member hospitals identified of clinical decision support is a cost- obesity as a priority health need.372 50 TFAH • RWJF The IRS estimates that nonprofit Healthy Food Procurement hospitals spent $62.4 billion on Healthcare facilities—particularly community benefit programs large institutions like hospitals—can in 2011,373 which include a wide require their food-service and vending- variety of initiatives, such as obesity- machine providers to offer healthier prevention activities like nutrition food choices to patients, visitors, and programs, physical activity programs, employees. The Healthy Food in Health school-based programs, and public Care Pledge assists the healthcare system awareness campaigns. in leveraging its purchasing power l B oston Children’s Hospital and building a healthier food system. supports Fitness in the City, a local More than 500 hospitals and food- program that helps children who service providers in the United States are overweight or have obesity meet and Canada have signed the pledge, fitness and physical activity goals. demonstrating their commitment to offering healthier options.377 CDC l aiser Permanente supports a K has also developed a tool to help Healthy Eating Active Living hospitals assess their food and beverage campaign in in 170 communities environment and make improvements.378 across the United States designed to improve community health with Breastfeeding Support a focus on reducing obesity and Children who are breastfed are at a chronic disease.374 Studies looking significantly reduced risk for obesity at health outcomes in some of these later in life.379 As nearly 99 percent of communities found the most success American babies are born in hospitals,380 in their youth initiatives, particularly these facilities can help reduce obesity those in schools and those related to by supporting breastfeeding during the increasing physical activity.375 critical postpartum period. Data trends l T he Genesys Regional Medical Center suggest that hospitals are improving their identified obesity-related diseases as breastfeeding support practices. In 2016, their top priority and, in collaboration 18.3 percent of children in the United with a variety of community States were born at facilities designated organizations, implemented a food as Baby Friendly.381 This was more than security and education program double the 2014 rate of 7.8 percent.382 to increase the availability and Most U.S. births, however, still take place consumption of healthy foods in the in facilities that lack this designation. To Flint, Michigan area.376 become accredited as Baby Friendly, a hospital must implement 10 evidence- based practices shown to increase breastfeeding initiation and duration, and it must restrict the marketing of breastmilk substitutes.383 TFAH • RWJF 51 Appendix STATE POLICY UPDATE Early Childhood Education Healthy Eating Physical Activity Screen Time Drinking Water Nutritional Breastfeeding (2018) (2018) (2018) (2018) (2018) Standards (2018) State requires State requires State requires State requires State requires licensed Early State reequires State requires State requires licensed ECE licensed ECE licensed ECE licensed ECE Childhood licensed ECE licensed ECE licensed ECE programs to programs to provide programs to have programs to Education (ECE) programs to programs to allow/ programs to have prohibit screen meals and snacks private space make drinking programs to have allow/encourage encourage onsite time for daily time for children that meet general available for water available to healthy eating breastfeeding breastfeeding physical activity under age 2 or USDA and/or breastfeeding children policies sets limits CACFP standards Alabama √L,Q √L √L,Q √L √L √L Alaska √L √L √L √L Arizona √L √L √L √L √L √L Arkansas √L,Q √L √L √L,Q √L √L √L California √L √L √L √L √L √L Colorado √L,Q √L √L √L,Q √L √L √L Connecticut √L √L √L Delaware √L,Q √L √L √L √L,Q √L √L D.C. √L √L √L √L √L √L √L √L Florida √ L √L √L √ L √L Georgia √L,Q √L √L √L,Q √L √L √L Hawaii √L √L √L √L Idaho √Q √Q Illinois √L √L √L √L Indiana √L,Q √L √L,Q √L,Q √L Iowa √L,Q √L √L √L Kansas √L √L √L Kentucky √L √L √L √L √L Louisiana √L √L √L √L √L Maine √L √L,Q √L √L Maryland √L,Q √L,Q √L,Q √L √L,Q Massachusetts √L,Q √L,Q √L √L Michigan √L,Q √L √L √L,Q √L √L √Q Minnesota √L,Q √L,Q √L √L Mississippi √L √L √L √L √L √L √L √L Missouri √ L √L √L Montana √L,Q √Q √L √L √Q Nebraska √L,Q √Q √L,Q √Q √L,Q Nevada √L,Q √L,Q √L,Q √L √L,Q √L √Q New Hampshire √L √L √L √L New Jersey √L,Q √Q √Q √L,Q √L √L √L New Mexico √L,Q √L,Q √L,Q √L √L New York √L,Q √L √L,Q √L,Q √L √L,Q North Carolina √L √L √L √L √L √L √L √L North Dakota √L,Q √L √L,Q √L √L,Q Ohio √L √L √L √L √L Oklahoma √L √L √L √L,Q √L,Q √L √L Oregon √L,Q √L,Q √Q √L √L Pennsylvania √L,Q √L,Q √L Rhode Island √L √L,Q √L √L √L South Carolina √L,Q √L,Q √L,Q √L √L,Q South Dakota √L √L Tennessee √L √L √L √L √L √L Texas √L,Q √L √L √L √L √L Utah √L,Q √Q √Q √Q √L,Q √L,Q √L,Q √L Vermont √L √L √L √L √L √L √L Virginia √L √L √L √L √L √L Washington √L,Q √L,Q West Virginia √L √L √L √L √L Wisconsin √ L,Q √L,Q √L √L √L,Q Wyoming √L √L Nemours State Policy Review on Obesity Prevention1 Note: √ = State has either licensing regulations, QRIS Stanadards or both. L= licensing regulations; Q = QRIS Standards 1. Source: Nemours Children’s Health System. “State Policy Review on Obesity Prevention.” August 2018. 52 TFAH • RWJF STATE POLICY UPDATE School Physical Activity (2018 report, based on 2016 data) Physical Education Recess/General Activity Requirements State requires at least State requires at least State requires at least State requires PE State has State has recess State recommends 40 minutes of PE in 40 minutes of PE in 40 minutes of PE in high credits for high school general activity requirements recess elementary school middle school school graduation requirements Alabama ≥150 min/week 150-224 min/week No Yes Alaska No No No No Arizona No No No No Arkansas 40-89 min/week 40-149 min/week No Yes √ √ California 90-149 min/week 150-224 min/week 150-224 min/week Yes √ Colorado No No No No √ Connecticut No No No Yes √ Delaware No No No Yes D.C. ≥150 min/week ≥225 min/week No Yes Florida ≥150 min/week No No Yes Georgia ≥150 min/week No No Yes Hawaii 40-89 min/week 150-224 min/week 150-224 min/week Yes Idaho No No No No Illinois No No No No Indiana No No No Yes √ Iowa No No No Yes √ √ Kansas No No No Yes √ Kentucky No No No Yes Louisiana ≥150 min/week 150-224 min/week No Yes √ Maine No No No Yes Maryland No No No Yes Massachusetts No No No No Michigan No No No Yes √ Minnesota No No No No Mississippi 40-89 min/week 40-149 min/week No Yes Missouri 40-89 min/week 40-149 min/week No Yes √ Montana No ≥225 min/week No Yes Nebraska No No No Yes Nevada No No No Yes √ New Hampshire No No No Yes √ New Jersey ≥150 min/week 150-224 min/week 150-224 min/week Yes New Mexico No No No Yes √ New York 90-149 min/week 40-149 min/week 40-149 min/week Yes North Carolina No No No Yes √ North Dakota 40-89 min/week 40-149 min/week No Yes Ohio No No No Yes Oklahoma 40-89 min/week No No No √ Oregon ≥150 min/week ≥225 min/week No Yes Pennsylvania No No No Yes Rhode Island 90-149 min/week 40-149 min/week 40-149 min/week No √ South Carolina 40-89 min/week No No Yes √ √ South Dakota No No No Yes Tennessee No No No Yes √ Texas No No No Yes √ Utah No No No Yes Vermont No No No Yes √ Virginia No No No Yes √ Washington 90-149 min/week 40-149 min/week No Yes West Virginia 90-149 min/week No No Yes Wisconsin No No No Yes Wyoming No No No Yes Safe Routes to School2 The Council of State Governments3 2. Lieberman M, Pasillas A, Pedroso M, Williams H, Zimmerman S. “Making Strides 2018: State Report Cards on Support 3. Whitehouse E, Shafer M. “State Policies on Physical Activity for Walking, Bicycling, and Active Kids and Communities.” Safe Routes to School National Partnership, 2018. https://www. in Schools.” The Council of State Governments, March 2017. saferoutespartnership.org/sites/default/files/resource_files/061218-sr2s-making-strides-2018_final.pdf (August 20, 2018). http://knowledgecenter.csg.org/kc/content/state-poli- cies-physical-activity-schools (August 20, 2018) TFAH • RWJF 53 STATE POLICY UPDATE School Nutrition Food Financing and Taxes State School Healthy Food Community Fundrasising Food School Lunch and School Breakfast Financing Sales Tax on Soda Eligibility Exemptions Authorities Programs (2016-2017) Initiative (2018)a (2016-2017) (2018) (2016) (2011-2017) Percent of eligible Free and Reduced Price School Breakfast Organization(s) in Soda treated Soda treated State policy Percent of districts adopting (FRP) Students in School Program Schools state awarded funding same as differently allows one or School Food the community Breakfast Program per 100 as % of National by the Community groceries than groceries more fundraising Authorities eligibility provision FRP Students in National School Lunch Development Financial for sales tax for sales tax exemptions Certified take-up School Lunch Program Program Schools Institution Fund determination determination Alabama 31.7 Yes 100 59.4 97.2 √b Alaska 78.8 Not specified 93.8 55.3 88.8 N/A N/A Arizona 32.2 Yes 99.8 54.4 94.4 √c Arkansas 25 Yes 98 63.8 99.9 √d California 15.1 No 99 56.3 89.1 √ √c Colorado 28.6 Yes 100 59.7 84.1 √ √c Connecticut 45.7 No 99 51.6 84.8 √c Delaware 76.5 No 98.1 62.3 99.6 N/A N/A D.C. 83 No 94 67.7 92.4 √c Florida 65.1 NS 100 51.1 98.6 √ √c Georgia 64.1 Yes 97.9 59.7 97.2 √ √c Hawaii 70.6 No 100 41.8 97.6 √b Idaho 46.8 Yes 100 58.7 95.8 √b Illinois 54 Not specified 100 47.6 83 √ √d Indiana 30 Yes 100 51.6 90.8 √c Iowa 30.8 No 99.6 43.8 93 √c Kansas 12.7 Yes 99.8 50.2 93.7 √b Kentucky 88.3 No 100 65 95.2 √ √c Louisiana 78 No 99 57 95.3 √ √b Maine 27.5 No Policy 96.7 60.8 96.4 √ √c Maryland 45.2 No 100 63.3 98.6 √ √c Massachusetts 36.9 No Policy 99.6 52.7 83.2 √ √c Michigan 48.1 Yes 100 59.3 91.6 √ √c Minnesota 40.4 No 99 53.9 87.7 √c Mississippi 36.9 No 100 59.7 94.7 √ √b Missouri 35.6 Yes 100 59.6 93.1 √d Montana 72.5 No 100 52 89.7 N/A N/A Nebraska 27.6 No 100 42.8 84.2 √c Nevada 71.4 No 100 63.9 94.9 √c New Hampshire 20 Yes 99 41.1 91.2 N/A N/A New Jersey 40.8 No 99.2 59.4 81.4 √c New Mexico 75.2 Yes 97.4 70.3 94.4 √c New York 55.4 No 100 52 93.8 √ √c North Carolina 62.8 No 100 58.4 98.6 √ √c North Dakota 85.7 Yes 100 49.6 89.5 √c Ohio 92.2 No Policy 100 56 87.5 √ √c Oklahoma 26.9 Yes 100 58.4 97.7 √ √b Oregon 64.5 No 99 53.8 95.5 N/A N/A Pennsylvania 46.6 Yes 93.5 50 91.2 √ √c Rhode Island 12 No 90.4 52.8 98.4 √c South Carolina 51.6 Yes 100 62.3 99.8 √ √c South Dakota 57.7 Yes 100 46.1 86.6 √b Tennessee 60.3 Not specified 100 65 98.3 √d Texas 31.6 Not specified 98 62.8 100.2 √ √c Utah 38.9 Yes 97 39.6 88.8 √d Vermont 63.6 No 94 66.2 96.4 √c Virginia 42.2 Not specified 100 59.3 98.5 √ √d Washington 36.1 No 100 45.5 93.4 √c West Virginia 87.3 No Policy 100 85.3 98.9 √c Wisconsin 52.7 Yes 100 51.7 81.3 √c Wyoming 71.4 Yes 98.5 43.9 91.5 √c Food Research Institute for U.S. Food Research Action Community Tax Foundation9 Action Center; U.S. Health Research Department of Center; U.S. Department of Development a ote: Sales taxes are distinct from soda excise taxes. N Department of and Policy5 Agriculture6 Agriculture7 Financial Sales taxes are lower and added at the register in- Agriculture4 Institutions Fund8 stead of within the shelf price-and thus less likely to impact consumption. b Groceries subject to sales tax c Groceries exempt from sales tax d Groceries taxed at lower rate than sales tax base 54 TFAH • RWJF STATE POLICY UPDATE Active Living Shared-Use Agreements (2018 report) Complete Street Policies (CSP) and Intent for Action (2018) State requires schools to State recommends State's CSP includes State's CSP includes State's CSP does not allow community access cooperation in allowing mandatory requirements State does not have mandatory requirements, include mandatory to school recreational community access to school for clear actions that shared use policy but does not have clear requirements or has not facilites outside of school recreational facilites outside demonstrate intent to action or intent adopted a CSP hours of school hours meet needs of all users 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 √ √ Safe Routes to School10 7. Food Research and Action Center. “School Breakfast Scorecard: School Year 2016-2017.” February 2018. 4. Food Research and Action Center. “Community Eligibility Continues to Grow in Available at: http://frac.org/wp-content/uploads/school-breakfast-scorecard-sy-2016-2017.pdf the 2016-2017 School Year.” March 2017. http://frac.org/wp-content/uploads/ 8. Community Development Financial Institutions Fund. “Searchable Awards Database, Basic Search, HFFI-FA CEP-Report_Final_Links_032317.pdf (August 20, 2018). Program.” 2018. https://www.cdfifund.gov/awards/state-awards/Pages/default.aspx (August 20, 2018). 5. Piekarz-Porter E, Lin W, Sanghera A, Chriqui JF. “Smart Snacks Fundraiser Ex- 9. Loughead K. “Sales Taxes on Soda, Candy, and Other Groceries.” Tax Foundation, Fiscal Fact No. 598, 2018. emption State Policies Quarterly Report.” University of Illinois at Chicago Institute Available at: https://files.taxfoundation.org/20180706104150/Tax-Foundation-FF598-Groceries-Soda-Candy. for Health Research and Policy, 2018. pdf (August 20, 2018) 6. Food and Nutrition Service. “Percent of SFAs Certified as of Sept 2016.” U.S. 10. Lieberman M, Pasillas A, Pedroso M, Williams H, Zimmerman S. “Making Strides 2018: State Report Cards Department of Agriculture, September 2016. Available at: https://fns-prod. on Support for Walking, Bicycling, and Active Kids and Communities.” Safe Routes to School National Partner- azureedge.net/sites/default/files/cn/SFAcert_FY16Q4.pdf ship, 2018. 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TFAH • RWJF 67 1730 M Street, NW, Suite 900 www.rwjf.org Washington, DC 20036 Route 1 and College Road East (t) 202-223-9870 P.O. Box 2316 (f) 202-223-9871 Princeton, NJ 08543-2316