Progress in Preventing Childhood Obesity

How Do We Measure Up?

Committee on Progress in Preventing Childhood Obesity

Jeffrey P. Koplan, Catharyn T. Liverman, Vivica I. Kraak, Shannon L. Wisham, Editors

Food and Nutrition Board

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Progress in Preventing Childhood Obesity: How Do We Measure Up? Progress in Preventing Childhood Obesity How Do We Measure Up? Committee on Progress in Preventing Childhood Obesity Jeffrey P. Koplan, Catharyn T. Liverman, Vivica I. Kraak, Shannon L. Wisham, Editors Food and Nutrition Board INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Progress in Preventing Childhood Obesity: How Do We Measure Up? THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The study was supported by Grant Nos. 052339 and 56982 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Progress in preventing childhood obesity : how do we measure up? / Committee on Progress in Preventing Childhood Obesity ; Jeffrey P. Koplan … [et al.], editors. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-309-10208-7 (hbk.) ISBN-10: 0-309-10208-1 (hbk.) 1. Obesity in children—United States—Prevention. 2. Child health services—United States—Evaluation. 3. Nutrition policy—United States—Evaluation. I. Koplan, Jeffrey. II. Institute of Medicine (U.S.). Committee on Progress in Preventing Childhood Obesity. [DNLM: 1. Child. 2. Obesity—prevention & control. WD 210 P964 2007] RJ399.C6P77 2007 618.92’398—dc22 2006037547 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Cover design by Samantha Razook Murphy. Cover photograph by Harrison Eastwood. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Progress in Preventing Childhood Obesity: How Do We Measure Up? COMMITTEE ON PROGRESS IN PREVENTING CHILDHOOD OBESITY JEFFREY P. KOPLAN (Chair), Woodruff Health Sciences Center, Emory University, Atlanta, GA ROSS C. BROWNSON, Department of Community Health, St. Louis University School of Public Health, MO ANN BULLOCK, Health and Medical Division, Eastern Band of Cherokee Indians, Cherokee, NC SUSAN B. FOERSTER, Cancer Prevention and Nutrition Section, California Department of Health Services, Sacramento, CA JENNIFER C. GREENE, Department of Educational Psychology, University of Illinois Urbana-Champaign DOUGLAS B. KAMEROW, Health, Social, and Economics Research, RTI International, Washington, DC MARSHALL W. KREUTER, Institute of Public Health, College of Health and Human Sciences, Georgia State University, Atlanta, GA RUSSELL R. PATE, Department of Exercise Science, University of South Carolina, Columbia JOHN C. PETERS, Food and Beverage Technology, Procter & GambleCompany, Cincinnati, OH KENNETH E. POWELL, Chronic Disease, Injury, and Environmental Epidemiology Section, Division of Public Health, Georgia Department of Human Resources (emeritus), Atlanta, GA THOMAS N. ROBINSON, Division of General Pediatrics and Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA EDUARDO J. SANCHEZ, Texas Department of State Health Services, Austin, TX ANTRONETTE (TONI) YANCEY, Department of Health Services and Center to Eliminate Health Disparities, UCLA School of Public Health, Los Angeles, CA Consultants SHIRIKI K. KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia DONNA NICHOLS, Senior Prevention Policy Analyst, Texas Department of State Health Services, Austin

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Staff VIVICA I. KRAAK, Co-Study Director CATHARYN T. LIVERMAN, Co-Study Director LINDA D. MEYERS, Director, Food and Nutrition Board SHANNON L. WISHAM, Research Associate JON Q. SANDERS, Senior Program Assistant (until June 2006) JESSICA COHEN, Christine Mirzayan Science and Technology Policy Graduate Fellow (June to August 2006)

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Progress in Preventing Childhood Obesity: How Do We Measure Up? FOOD AND NUTRITION BOARD* DENNIS M. BIER (Chair), Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX MICHAEL P. DOYLE (Vice Chair), Center for Food Safety, University of Georgia, Griffin DIANE BIRT, Center for Research on Dietary Botanical Supplements, Iowa State University, Ames YVONNE BRONNER, School of Public Health and Policy, Morgan State University, Baltimore, MD SUSAN FERENC, Chemical Producers and Distributors Association, Alexandria, VA NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver REYNALDO MARTORELL, Department of Global Health, Emory University, Atlanta, GA J. GLENN MORRIS, JR., Department of Epidemiology and Preventive Medicine University of Maryland School of Medicine, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA JIM E. RIVIERE, College of Veterinary Medicine, North Carolina State University, Raleigh NICHOLAS J. SCHORK, Department of Psychiatry, Polymorphism Research Laboratory, University of California, San Diego REBECCA J. STOLTZFUS, Division of Nutritional Sciences, Cornell University, Ithaca, NY JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Boston, MA BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ANTON L. BANDY, Financial Associate * IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the report rests with the authoring committee and the institution.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Independent Report Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: HEIDI ARTHUR, The Ad Council, New York, NY BILL BEERY, Group Health Community Foundation, Seattle, WA LORELEI DISOGRA, Nutrition and Health, United Fresh Fruit and Vegetable Association, Washington, DC STEPHEN B. FAWCETT, Work Group for Community Health and Development/World Health Organization (WHO), University of Kansas, Lawrence VANESSA NORTHINGTON GAMBLE, National Center for Bioethics in Research and Health Care, Tuskegee University, AL DEBRA HAIRE-JOSHU, Department of Community Health, Saint Louis University School of Public Health, St. Louis, MO SUSAN L. HANDY, Department of Environmental Science and Policy, University of California, Davis

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Progress in Preventing Childhood Obesity: How Do We Measure Up? CATHY KAPICA, former Global Director of Nutrition, McDonald’s Corporation, Oakbrook, IL JOE THOMPSON, Surgeon General, State of Arkansas and Arkansas Center for Health Improvement, Little Rock BRIAN WANSINK, Department of Applied Economics and Management, Cornell University, Ithaca, NY Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by CUTBERTO GARZA, Boston College. Appointed by the National Research Council, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Preface The remarkable growth of obesity in the young population in many parts of the world in a relatively short time span represents one of the defining public health challenges of the 21st century. At this early phase in addressing childhood obesity, action has begun on a number of levels to improve dietary patterns and increase physical activity in children and youth throughout the United States and in other countries. Schools, corporations, youth-related organizations, families, communities, foundations, and government agencies are working to implement a variety of policy changes, new programs, and other interventions. There is a great deal yet to be learned about how to evaluate these efforts and disseminate information on effective interventions. Additionally, lessons learned from other public health concerns such as the prevention of youth tobacco use and alcohol consumption can provide insights and directions for further efforts. However, the solutions to tobacco and alcohol consumption among our young people cannot be fully replicated due to the complexity of obesity and the ubiquity of food, sedentary habits, and familiar routines in our culture that contribute to the problem. A comprehensive response to the obesity epidemic requires connectivity, consistency, and continuity across multiple programs and sectors. Preventing childhood obesity will involve changes in social norms and the demand by the general public for healthier lifestyles and the products and opportunities that support physical activity and healthful diets. Innovations are needed that accelerate the pace of change that will move us toward these goals.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? In 2002, the Institute of Medicine (IOM) responded to a congressional mandate by developing an action plan for preventing childhood obesity. The IOM report Preventing Childhood Obesity: Health in the Balance provided recommendations for further action by multiple stakeholders. As a natural outcome of that report, IOM established the Committee on Progress in Preventing Childhood Obesity in 2005 with support from the Robert Wood Johnson Foundation. The IOM committee was charged with undertaking a study to assess the nation’s progress in preventing childhood obesity. It was also asked to engage in a dissemination effort promoting the implementation of the report’s findings and recommendations through three symposia that were held in Atlanta, Georgia; Irvine, California; and Wichita, Kansas. This report, Progress in Preventing Childhood Obesity: How Do We Measure Up?, places a specific focus on the evaluation of actions taken by all sectors of society and describes progress made toward the first report’s recommendations. Evaluation is vital to identify effective interventions that can be scaled up to statewide or nationwide efforts, while ineffective interventions can be replaced with more promising evidence-based efforts. As the Health in the Balance report acknowledged, we must draw from the best available evidence rather than waiting for the best possible evidence to mount an effective and sustained response. Along the way, we must ask whether the interventions to promote healthful eating and increase physical activity are reaching enough people to make a substantial difference, and whether the breadth of interventions are adequate to address the scope of the problem. An expanded and diverse evidence base will provide the foundation for a sustained effort toward reversing the current childhood obesity trends and improving the health and well-being of America’s children and youth. We have made considerable progress in five years since the release of the Surgeon General’s Call to Action. However, there is a great deal more work that all of us collectively need to undertake in order to adequately address the impending obesity crisis and thereby chart a healthier course for our future generations. Jeffrey P. Koplan, Chair Committee on Progress in Preventing Childhood Obesity

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Acknowledgments It was a great pleasure to chair the Institute of Medicine (IOM) Committee on Progress in Preventing Childhood Obesity. The 13-member committee brought tremendous expertise to this important topic from a variety of perspectives and was actively engaged in the committee’s work. This report represents the result of six meetings, two public workshops, three regional symposia, and ongoing communication throughout the course of the study. It is also the result of a thoughtful analysis and interdisciplinary collaboration among the committee members who volunteered countless hours of their valuable time to complete this study. I would like to extend my sincere thanks to each of the committee members for their commitment to work through the issues addressed in this report. This study was sponsored by the Robert Wood Johnson Foundation (RWJF). The committee and staff wish to thank RWJF staff including Risa Lavizzo-Mourey, James Marks, Kathryn Thomas, and Laura Leviton for their support and guidance on the committee’s task during the course of the study. The committee also benefited from discussions with individuals who presented at or attended the committee’s workshops, symposia, and meetings. We especially appreciate the contributions of Loel Solomon and Scott Gee from Kaiser Permanente; Susan Yanovski from the National Institute of Diabetes & Digestive & Kidney Diseases; Janet Collins from the Centers for Disease Control and Prevention (CDC); Penelope Royall from the U.S. Department of Health and Human Services (DHHS) Office of Disease Prevention and Health Promotion; Richard Kelly from the Federal Trade Commission; Eric Hentges from the U.S. Department of Agriculture; and Dana Carr from the U.S. Department of Education. I would especially like to

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Progress in Preventing Childhood Obesity: How Do We Measure Up? thank Kathryn Thomas at the RWJF; Marni Vliet, Steve Coen, and Deanna Van Hersh at the Kansas Health Foundation; Gary Nelson, Martha Katz, Meg Watson, and Allison Maiuri at the Healthcare Georgia Foundation; and Robert Ross, George Flores, and Marion Standish at The California Endowment for collaborating with the committee and staff to organize and co-host the regional symposia. The symposia agendas and speakers are listed in Appendixes F, G, and H. Many individuals were instrumental in providing useful data to the committee that was included in the report. We greatly appreciate the work and insights of Shiriki Kumanyika and Donna Nichols who served as consultants to the committee. We thank Bill Dietz, Edward Hunter, and Lynda Williams from CDC. We also thank Alison Kretser and Marjorie Goldstein for providing useful information used in the report. We would like to especially thank Tim Lobstein from the International Obesity Taskforce in London for sharing information about other country strategies and action plans to promote healthful eating, physical activity, and prevent obesity. Enrique Jacoby, Juan Rivera, Carlos Monteiro, and Fernando Vio were helpful in guiding the committee to obesity prevention activities and strategies in Latin America. Francesco Branca, Elina Hirvikallio, Raija Kara, Tim Lang, Wolf-Martin Maier, Canice Nolan, Philippe Roux, and Alberto Galvão A. A. Teles provided useful information about obesity prevention activities, strategies, and action plans in Europe. We appreciate the constructive input offered by the reviewers of this report who provided a technical review of sections of the report. Special thanks are extended to Michael McGinnis and Rosemary Dederichs for their technical review of selected chapters. We also acknowledge the financial oversight of Anton Bandy and Gary Walker. The committee benefited greatly from the skillful copyediting of the report by Michael Hayes, cover design by Samantha Razook Murphy, and chapter illustrations by Becky Heavner. Finally, a study of this scope is only possible with the assistance of the IOM staff. I would like to thank co-study directors, Cathy Liverman and Vivica Kraak, research associate Shannon Wisham, board director Linda Meyers, policy fellow Jessica Cohen, and senior program assistant Jon Sanders for their steadfast devotion to the study process and final report. Progress in Preventing Childhood Obesity: How Do We Measure Up? presents recommendations relevant to implementing and evaluating obesity prevention interventions within and across many sectors—government, industry, communities, schools, and home—and urges all sectors and invested stakeholders to take the collective actions needed to improve the health and well-being of children and youth. Jeffrey P. Koplan, Chair Committee on Progress in Preventing Childhood Obesity

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Contents     SUMMARY   1 1   INTRODUCTION   17 2   FRAMEWORK FOR EVALUATING PROGRESS   32 3   DIVERSE POPULATIONS   74 4   GOVERNMENT   109 5   INDUSTRY   167 6   COMMUNITIES   228 7   SCHOOLS   280 8   HOME   326 9   ASSESSING THE NATION’S PROGRESS IN PREVENTING CHILDHOOD OBESITY   351

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Progress in Preventing Childhood Obesity: How Do We Measure Up?     APPENDIXES     A   Acronyms   367 B   Glossary   372 C   Data Sources, Indicators, and Evaluation Tools for Measuring Progress in Childhood Obesity Prevention   390 D   Examples of Recent Federal Agency Programs, Initiatives, and Surveillance Systems for Supporting and Monitoring the Prevention of Obesity in U.S. Children and Youth   395 E   Compilation of Recommendations and Implementation Actions   412 F   IOM Regional Symposium Progress in Preventing Childhood Obesity: Focus on Schools   424 G   IOM Regional Symposium Progress in Preventing Childhood Obesity: Focus on Communities   429 H   IOM Regional Symposium Progress in Preventing Childhood Obesity: Focus on Industry   434 I   Biographical Sketches of Committee Members and Staff   437     INDEX   449 * The complete symposia summaries for Appendixes F through H (pages 424–436) are not printed in this report. They are included on a CD-ROM attached to the inside back cover.

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Progress in Preventing Childhood Obesity: How Do We Measure Up? Progress in Preventing Childhood Obesity

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