Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 33
Perspectives on the Prevention of Childhood Obesity in Children and Youth Government Perspective William Dietz DR. DIETZ: Thank you, Dr. Koplan. It really is a pleasure to be here with you this evening at the Rosenthal lecture. I would like to comment on my agenda item. I am not going to give you the entire “government perspective,” but rather, the perspective of the Center for Disease Control and Prevention (CDC) on this problem. What I am going to try to demonstrate is that one of the CDC’s most important functions is to catalyze change. Many of our efforts in the field of obesity, I think, have been directed toward that end. I would like to begin by comparing the obesity epidemic with the spread of tobacco, which can be divided into three phases. This first phase was a rapid increase in the use of per capita tobacco consumption. The second phase was a plateau in tobacco consumption, which occurred when tobacco became a visible health problem. The third phase was a decline in tobacco consumption that was driven by multiple overlapping interventions. From the perspective of the CDC, our efforts have paralleled in some respects the developments that led to the decline of tobacco. Our first efforts focused on increasing the visibility of this problem. In our second focus, we focused on the disease burden, which has particular implications for the pediatric population. The third effort, we began to identify interventions and to develop the partnerships necessary to move those interventions forward.
OCR for page 34
Perspectives on the Prevention of Childhood Obesity in Children and Youth Those are the main areas which I would like to focus on tonight. Our efforts to increase visibility began with a series of maps which I think are known to many of you. We published these maps beginning in 1999, when Dr. Koplan was the chief author of an editorial announcing that obesity was epidemic. As you know, all of these maps look the same. There are the obesity trends among U.S. adults from the Behavioral Risk Factor Surveillance System, a state-based annual survey. Prevalence estimates are down here. An estimate of less than 10 percent is this light blue, 10 to 14 percent is this medium blue, and the dark blue is 15 to 19 percent. As the epidemic progressed, the number of states that were affected rapidly increased until 2003. There was no question in anyone’s mind that this was an epidemic. The impact of this series of maps has been striking. More than anything else, it has made this epidemic visible. You don’t have to look further than the issue of Time magazine that followed the Time/ABC conference in Williamsburg. In addition, who would ever have thought that National Geographic would have an issue on obesity, or that Sports Illustrated would begin to talk about obesity and physical fitness, or that Vogue would address obesity in a lengthy, but somewhat scary article for women who are afraid of turning into the shapes that Vogue included in this particular article. All of this has accomplished the goal of making the obesity issue visible. That is behind us. Now, in many respects, I think we are confronting an even bigger challenge, and that is, what do we do? How do we begin to change behaviors that lead to obesity? Our focus, with respect to the pediatric population, has been to look hard at what the implications of pediatric obesity are for adult disease. These are data from Bogalusa, Louisiana; they are the only data of their kind, which looked at the course obesity in childhood and its impact on adult disease. I think you can see that only 25 percent of adults were overweight children but, among overweight children who went on to become obese adults, there was a disproportionate representation of that group among the severely obese. Half of the all adults with a BMI over 40—that is, half of all adults
OCR for page 35
Perspectives on the Prevention of Childhood Obesity in Children and Youth who are 100 pounds or more overweight—were overweight prior to eight years of age. In our view, that is a disproportionate contribution to the burden of disease. Ultimately, whether childhood onset obesity that persists into adulthood it is more expensive than adult-onset obesity is not yet resolved, but the contribution of childhood onset obesity to adult obesity provides a sound rationale for dealing with obesity in children. Over the last four years, we have channeled funds to 28 states to develop interventions. Five of these states are funded at a basic implementation level. These states are looking for solutions. At the same time, the Steps Program, which is a program initiated by Secretary Thompson, is focusing on dealing with diabetes, obesity, and asthma through nutrition, physical activity, and tobacco control. So, what do we recommend? What actions does the evidence justify today? We spent a lot of time, and more needs to be spent, in identifying reasonable efforts that are likely to be effective for this problem. The most evidence exists for the role of physical activity, which reduces obesity-associated comorbidities. That is, if you were overweight, hypertensive, and inactive, and you become active, then your blood pressure would improve. Physical activity has a relatively modest impact on weight loss, and the dose of physical activity necessary to prevent obesity is not known. Nonetheless, physical activity is a strategy that we can employ today, if only for its impact on the comorbidities. We also have a sound evidence base included in the Guide for Community Preventive Services, with recommended strategies to increase physical activity, both at the individual and community level. Television viewing was mentioned earlier. There is a strong relationship of television viewing to both the prevalence and severity of obesity in children, and there is increasing evidence that reductions in television time reduce childhood obesity. Finally, children who were ever breast fed and children who were breast fed for longer periods of time have a reduced risk of early childhood overweight. Although the effects of breastfeeding may be confounded by other variables, for all the other reasons for which we should be supporting breast feeding, weight control
OCR for page 36
Perspectives on the Prevention of Childhood Obesity in Children and Youth may be an additional strategy, particularly insofar as it may affect those children who are most vulnerable and most likely to go on to severe adult disease. These are promising interventions. We have less evidence to support these interventions, but they can be rationally and logically implemented with no adverse effects. In addition to all the reasons we support fruit and vegetable intake, consuming fruits and vegetables may also have an impact on obesity. Satiety seems to be regulated by volume, not by calories, and foods that have a large volume and are relatively low in calories may reduce subsequent caloric intake and, thereby, reduce obesity. Soft drink consumption accounts for about 13 percent of daily caloric intake for adolescents, and reductions in soft drink intake or substitutions of low-calorie beverages seems a logical strategy to reduce obesity. Already mentioned by Dr. Koplan and Dr. Kumanyika is the strategy of reducing portion size. Because of the urgency of the epidemic, we can’t wait, in these areas, for the substantial body of randomized clinical trials necessary to meet the evidentiary standards of something like the Guide for Community Preventive Services. The strategy that we are now pursuing is nicely summarized by this quote from Larry Green: “To obtain more evidence-based practice, we need more practice-based evidence.” We need to understand the impact of the natural experiments that are going on around us. When a school changes the products in its vending machines, or eliminates vending machines, what impact does that have on the quality of the diet or on weight? When the Texas school system reintroduces physical education in its elementary school programs, what impact does that have on weight? To build more evidence-based practice, we need more practice-based evidence. We have also been actively looking at interventions delivered through different venues. The first of these is medical settings, which we still see as a public health intervention, because medical settings are where the 16 percent of children and adolescents who are overweight are going to go to obtain their health care. We have partnered with Kaiser Permanente to begin to explore how to
OCR for page 37
Perspectives on the Prevention of Childhood Obesity in Children and Youth change the delivery of care for a chronic disease such as obesity. The chronic care model involves changing such things as the information systems available in medical settings so that BMI, or body mass index, becomes a vital sign, and is entered in the medical record just like blood pressure but, in this case, could be linked to an algorithm for the care of obesity. Changes in decision support are represented by this poster, which Kaiser Permanente developed and posted in all their pediatric examining rooms. It is designed to engage children and parents in conversations about how to get more energy. Notice that it is about energy, not about obesity. Many of the recommendations that I emphasized, such as being physically active for 60 minutes a day, reducing television time, substituting water for soft drinks, and increasing fruit and vegetable consumption are reiterated in this poster. In addition, along the bottom of this poster is a scale for readiness to change, which the health care providers can use to engage patients in discussing behavior change around these behaviors. Increasingly, medical systems are recognizing that changes in the medical system delivery alone are not sufficient to achieve optimal patient self-management. The most recent development has been the recognition by enlightened groups such as Kaiser Permanente and Blue Cross Blue Shield of Massachusetts that they need to partner with public health systems that address nutrition, physical activity, and obesity in schools, at work sites, and in communities. As a result of this recognition, Kaiser Permanente has partnered with a number of the Steps Program applicants, and is actively partnering with some of those recipients to develop community-based approaches. These partners have introduced a community health initiative that provides funds for communities to invest in nutrition and physical activity interventions to address obesity in schools and communities. Blue Cross Blue Shield in Massachusetts has developed a program called 5–2–1 in collaboration with our state program in Massachusetts. 5–2–1 stands for five fruits and vegetables a day, two hours or less of television a day, and one hour of physical activity a day.
OCR for page 38
Perspectives on the Prevention of Childhood Obesity in Children and Youth These kinds of partnerships, I think, are going to be essential to achieve optimal patient self-management. Not only will this require shifts in the medical system, but complementary shifts in the environment as well if those changes are to be achieved. I am not going to talk about schools. You have already heard something about this from both Mr. Leach and Dr. Kumanyika, and we can talk about more of this in the discussion. I want to spend the last two minutes on communications strategies. One of the most important deficits that I feel we have in this field is that we don’t have redundant messages about weight control. The strategies I outlined earlier need to be heard both in the health care provider’s office, in schools, and echoed in work sites and communities. We need that kind of redundancy and consistency. One of the most important CDC efforts in this arena has been a campaign known as VERB. This is a media campaign aimed at “tweens,” children ranging from 9 to 13 years old. It is called VERB because there are 10,000 active verbs in the English language. You can run, jump, swim, play, throw, and so on. The campaign is aimed at getting children to pick their own verb. One of the most important aspects of this campaign is that it is a paid advertising campaign. It is a paid media campaign rather than a campaign that relies on public service announcements. At its outset, the campaign had sufficient funding to do the kind of necessary focus group work to develop specific ads aimed at the five major groups of children in the country. So, there are ads specific for children who are Caucasian, African American, Mexican American, Native American, and Asian American children. I would like to show you one of these ads. This is the ad for Native American children. [Video shown] The VERB campaign has been one of the more effective advertising campaigns, probably because it has been one of the most well supported. There have been very significant improve-
OCR for page 39
Perspectives on the Prevention of Childhood Obesity in Children and Youth ments in physical activity levels among target populations who are considered most vulnerable, namely, girls, inner-city children, and children from low-income families. In closing, I think we know some of the things we need to do. Now the challenge is how do we begin to implement these strategies more broadly? I think that the quote that summarizes our challenge and commitment best is this quote from Margaret Mead who said: “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.” My belief is that we have a small and committed group of people who are focused on the issue of childhood obesity, and this is a world that can change. My belief is that it will not take us the 80 years it took the Red Sox to win the World Series. Thank you. DR. KOPLAN: Thank you, Dr. Dietz.
OCR for page 40
Perspectives on the Prevention of Childhood Obesity in Children and Youth This page intentionally left blank.
Representative terms from entire chapter: