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2
Assessing the Current Situation
Key Messages
• Populationwide obesity has serious health, economic, and social conse-
quences for individuals and for society at large.
• Almost one-third of children and two-thirds of adults in the United States
are overweight or obese.
• Although the vast majority of people who are obese are not poor or racial/
ethnic minorities, the percentage of people within poor and ethnic minority
populations who are affected by obesity is relatively higher, sometimes
markedly so, for one or both sexes compared with the nonpoor or whites.
Particular attention to these high-risk groups is essential in obesity preven-
tion efforts.
• Causes of the high rates of obesity can be traced to trends in environmental
influences on physical activity and food intake.
• Important advances have occurred in national guidance, policy, research
directions, and partnership initiatives, as well as consensus on the need for
a broad, prevention-oriented approach to the obesity epidemic. However,
direct opposition to some potential obesity prevention strategies impedes
their acceptance and implementation.
• Evidence that levels of obesity may be stabilizing may be an important sign
that these advances are having a positive effect. However, complex realities
associated with the obesity epidemic give rise to several considerations—
including some that can serve as major roadblocks—that must be addressed
when measures are taken to accelerate preventive efforts.
33
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T he process of developing strategies to accelerate obesity prevention begins with
a situation assessment. This chapter provides such an assessment by present-
ing data on the consequences the nation faces if the epidemic persists; the starting
point for acceleration of preventive efforts with respect to obesity prevalence in
the general population and in populations at particularly high risk; contributory
trends related to physical activity, food intake, and media use and other factors
relevant to sedentary behavior; and positive steps that have already been taken
and have momentum, along with the roadblocks that could limit further advances.
The nature of change trajectories needed to track progress toward the goal of see-
ing obesity levels decline is also discussed.
HUMAN AND SOCIETAL CONSEQUENCES OF THE
OBESITY EPIDEMIC
The consequences of today’s high rates of obesity have two broad dimensions.
The first is the direct and sometimes devastating health and social consequences
to individuals—the potential for illness or disability, social ostracism, discrimina-
tion, depression, and poor quality of life. The second dimension encompasses the
indirect effects of obesity on society, reflected in population fitness, health care
costs, and other aspects of the economy.
Human Costs
As shown in Table 2-1, obesity is associated with major causes of death and
disability, as well as with psychosocial consequences that impair functioning and
quality of life. The effect of obesity in predisposing to the development of type 2
diabetes is particularly strong, so much so that the onset of this disease—formerly
observed only in adults—also now occurs during childhood (CDC, 2011). Adverse
effects are observed throughout the life course and may be transmitted from
mother to child through the characteristics of the gestational environment (IOM,
2009). According to current estimates, one-third of all children born today (and
one-half of Latino and black children) will develop type 2 diabetes in their life-
time (Narayan et al., 2003). One dire projection is that obesity may lead to a
generation with a shorter life span than that of their parents (American Heart
Association, 2010; Olshansky et al., 2005).
The highest prevalence of obesity-related conditions occurs in middle-aged and
older adults, with direct effects on quality of life and on rates of disease, disability,
and death at an early age. High blood pressure is the most prevalent of these con-
Accelerating Progress in Obesity Prevention
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TABLE 2-1 Physical Health, Psychosocial, and Functional Consequences of
Obesity Over the Life Course
Physical Health Psychosocial Functional
• Cardiovascular disease • Stigma • Unemployment
• Cancer • Negative stereotyping • Mobility limitations
• Glucose intolerance and insulin • Discrimination • Disability
resistance • Teasing and bullying • Low physical fitness
• Type 2 diabetes • Social marginalization • Absenteeism from school or
• Hypertension • Low self-esteem work
• Dyslipidemia • Negative body image • Disqualification from active
• Hepatic steatosis • Depression service in the military and
• Choleslitasis fire/police services
• Sleep apnea • Reduced productivity
• Reduction of cerebral blood flow • Reduced academic
• Menstrual abnormalities performance
• Orthopedic problems
• Gallbladder disease
• Hyperuricemia and gout
SOURCE: Adapted from IOM, 2010a.
ditions, and is a major risk factor for cardiovascular diseases. High blood pressure
affects a third of U.S. adults aged 20 and over and more than half of adults aged
55 and older. Together high blood pressure, coronary heart disease, heart failure,
and stroke affect 37 to 39 percent of women and men aged 40 to 59 and 72 to
73 percent of women and men aged 60 to 79. Eight percent of adults have a diag-
nosis of type 2 diabetes, another 3 percent are undiagnosed, and an additional
37 percent have prediabetes (Roger et al., 2011). Both high blood pressure and dia-
betes (diagnosed and undiagnosed) increased between 1988-1994 and 2005-2008
at the same time that increases in obesity were observed (see below). And a grow-
ing literature suggests various types of reductions in brain structural integrity (due
to low blood flow to the brain) among both obese adolescents and adults (Gunstad
et al., 2006; Maayan et al., 2011; Willeumier et al., 2011). In addition to these
physical risks, obese adults face discrimination in employment settings and are sub-
jected to inappropriate slurs and humor (Puhl and Heuer, 2001; Wear et al., 2006).
Obese children and adolescents also suffer an array of obesity-related comor-
bidities, ranging from sleep apnea, to type 2 diabetes, to hypertension, to liver
disease, to orthopedic problems. These conditions over time may contribute to
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Assessing the Current Situation
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shorter lifespans for obese children and adolescents. Poor health-related quality
of life—physical, psychosocial, emotional, social, and school functioning—is 5.5
times greater in obese children and adolescents than in their normal-weight peers
(Schwimmer et al., 2003). Childhood obesity is a major contributor to chronic ill-
ness and accounts for increased use of medication and physician visits and associ-
ated loss of school time (Van Cleave et al., 2010). Data suggest that obese children
and adolescents miss more school days than their normal-weight peers regardless
of age, ethnicity, sex, and school attended (Geier et al., 2007). And overweight
or obese children and adolescents in every grade experience poorer academic out-
comes than their normal-weight peers (Taras and Potts-Datema, 2005).
Box 2-1 puts a human face on a day in the life of obese children and adoles-
cents. A study of adolescents found that nearly 30 percent of girls and 25 per-
cent of boys were teased by peers about their weight, and 29 percent of girls
and 16 percent of boys were teased by family members (Eisenberg et al., 2003).
Teasing about weight is associated with depression, low self-esteem and body
satisfaction, and suicidal thoughts and attempts (Eisenberg et al., 2003). Obesity
associates individuals with “different” negative stereotypes, which can encourage
others to stigmatize them and discount their worth (Gray et al., 2011; Vander Wal
and Mitchell, 2011; Williams et al., 2008).
Economic and Societal Costs
Economic and societal costs (see Table 2-2) are linked to the impact of the
outcomes shown previously in Table 2-1 on health care costs and productivity.
Many health care expenditures are both a direct and indirect result of the current
epidemic of overweight and obesity (Wolf, 1998; Wolf and Colditz, 1998). Direct
costs include preventive, diagnostic, and treatment services related to obesity; indi-
rect costs are those associated with morbidity and mortality. The estimated annual
cost of obesity-related illness based on data from the Medical Expenditure Panel
Survey for 2000-2005 is $190 billion (in 2005 dollars), which represents 20.6 per-
cent of annual health care spending in the United States (Cawley and Meyerhoefer,
2011). Childhood obesity alone is responsible for $14.1 billion in direct medical
costs (Trasande and Chatterjee, 2009).
Recent studies have modeled the economic benefits of reducing obesity preva-
lence in the U.S. population. Obesity is the major modifiable risk factor for the
development of diabetes and also increases the risk of developing hypertension. It
is estimated that reducing the prevalence of diabetes and hypertension by 5 per-
cent would save approximately $9 billion annually in the near term; with resulting
Accelerating Progress in Obesity Prevention
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BOX 2-1
Childhood Days: Stories from Life*
For many children and adolescents who are overweight or obese, childhood is a
gauntlet of disappointment, depression, and disease. For example:
• Mark and Kathy bring their 3-year-old child to a health clinic. Both parents
are obese. They are adamant: “We do not want our child to go through
what we did as children.”
• Jonathan is 9 years old. He has sleep apnea, and must wear a heavy device
on his face at night. This means he must take his “machine” for overnight
visits with friends and relatives and try to explain why he is “different.”
• Kelly is 10 years old. She is depressed and has suicidal thoughts. She
reports, “The teasing starts on the bus to school, continues through the
school day, and all the way home.” She has changed schools, but the teas-
ing has only started again.
• Tasha is an obese 15-year-old who loves soccer. She did well on the school
team last year, but worries constantly that she won’t make the team next
fall because of her weight.
• Marco is 17 years old, with obesity and hypertension. Asked about his plans
for the future, he responds with emotion, “I’ve always wanted to become a
firefighter, but I know I won’t be able to because of my weight.”
Similar stories about the challenges of living with obesity as an adult would
remind us of the day-to-day burdens of living with hypertension, diabetes, or
knee pain; the trips to doctors’ offices; and the costs and side effects of medi-
cation. Too often, the immediate response to life stories such as these can be,
“Why don’t they just lose weight?” Yet data show that contemporary culture,
economics, and society pose many barriers to the types of healthy diets that
prevent obesity from occurring and to the difficult tasks of losing excess weight
and sustaining lower weight levels.
*The individuals described in these illustrative examples are real pediatric patients; names
have been changed for confidentiality.
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TABLE 2-2 The Key Costs Identified from Research on the Economic Impact of
Obesity
Cost Category Subcategories Key Results, and Range of Estimates
Direct medical Relative medical costs for overweight (vs. normal weight)
spending
Relative medical costs for obese (vs. normal weight)
Annual direct costs of childhood obesity
U.S.-wide annual cost of “excess” medical spending
attributable to overweight/obesity
Productivity Absenteeism Excess days of work lost due to obesity
costs
Relative risk ratio of having “high absenteeism”
National costs of annual absenteeism from obesity
Presenteeism National annual costs of presenteeism obesity
Relative productivity loss due to obesity
Disability Relative risk ratio of receiving disability income support
Premature Years of life lost due to obesity
mortality
QALYs lost due to obesity
Total National annual indirect costs of obesity
Accelerating Progress in Obesity Prevention
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Relative Costs Total Costs Total Nondollar Amounts
10-20% highera,b
36-100% highera-d
$14.3 billione,f
$86-147 billion (total)c
$640 billion (women 40-65 only)g
1.02-4.72 daysh-j
1.24-1.53 times higherj,k
$3.38-6.38 billion, or $79-132 per
obese personj,l
$57,000 per employeel (1998 USD)
$8 billionm (2002 USD)
1.5% higherj
5.64-6.92 percentage
points highern
1-13 years per obese persono
2.93 million QALYs total in
U.S. in 2004p
$5 (1994 USD)-$66 billionm,q
continued
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Assessing the Current Situation
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TABLE 2-2 Continued
Cost Category Subcategories Key Results, and Range of Estimates
Transportation Fuel costs Annual excess jet fuel use attributable to obesity
costs
Annual excess fuel use by noncommercial passenger
highway vehicles
Additional fuel required in noncommercial passenger
highway sector per lb of average passenger weight increase
Environmental OECD-wide CO2 emissions from transportation per 5 kg
costs average weight per person
Human capital Highest grade completed
accumulation
costs
Days absent from school
NOTES: OECD = Organisation for Economic Co-operation and Development; QALY = quality-adjusted
life-years.
aThompson et al., 1999; bThompson et al., 2001; cFinkelstein et al., 2009; dThorpe et al., 2004; eCawley,
2010; fTrasande and Chatterjee, 2009; gGorsky et al., 1996; hPronk et al., 1999; iTsai et al., 2008; jTrogdon
et al., 2008; kSerxner et al., 2001; lDurden et al., 2008; mRicci and Chee, 2005; nBurkhauser and Cawley,
2004; oFontaine et al., 2003; pGroessl et al., 2004; qThompson et al., 1998; rDannenberg et al., 2004;
sJacobson and King, 2009; tJacobson and McLay, 2006; uMichaelowa and Dransfield, 2008; vGortmaker et
al., 1993; wKaestner et al., 2009; xGeier et al., 2007.
SOURCE: Reprinted with permission from Diabetes, Metabolic Syndrome and Obesity: Targets and
Therapy, volume 3, Hammond, R. A., and R. Levine, The economic impact of obesity in the United States,
pages 285-295, Copyright 2010, with permission from Dove Medical Press Ltd.
reductions in comorbidities and related conditions, savings could rise to approxi-
mately $24.7 billion annually in the medium term (Ormond et al., 2011).
Many of these obesity-related health care costs are paid with public dollars.
For example, it is estimated that total Medicare and Medicaid spending would
be 8.5 percent and 11.8 percent lower, respectively, in the absence of obesity
(Finklestein et al., 2009). Moreover, these health care costs are expected to rise
significantly, since today’s increased rates of childhood obesity predict further
increases in adult obesity and concomitant increases in hypertension, stroke, dys-
lipidemia, cancers (endometrial, breast, and colon), osteoarthritis, sleep apnea,
liver and gall bladder disease, respiratory problems, and type 2 diabetes.
Accelerating Progress in Obesity Prevention
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Relative Costs Total Costs Total Nondollar Amounts
350 million gallonsr
$742 million (2010 USD)
938 million-1 billion gallonss,t
$2.53-2.7 billion (2010 USD)
39 million gallonst
$105 million per lb (2010 USD)
10 million tonsu
0.1-0.3 fewer grades
completedv,w
1.2-2.1 more days
absent from schoolx
The U.S. economy struggles today to cope with health care spending; this
struggle will grow progressively more difficult as today’s obese children mature.
Beyond growing medical costs attributed to obesity, the nation will incur higher
costs for disability and unemployment benefits. Businesses currently suffer because
of obesity-related job absenteeism ($4.3 billion annually) (Cawley et al., 2007);
these costs also will continue to grow. Societal expenses add to the effects of the
reduced standard of living and quality of life experienced by affected individuals
and their families.
Obesity has economic implications even in the absence of health detriments.
For example, employers are less likely to hire obese than normal-weight indi-
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Assessing the Current Situation
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viduals with the same qualifications; when hired, obese individuals are likely to
report being paid lower wages and suffering other additional discrimination (Giel
et al., 2010; Han et al., 2011). The result is underutilization of available skills at
a cost to both society and individuals. The economic repercussions of discrimina-
tion affect families as well. Because decreased fitness in obese people may lead to
increased health problems (IOM, 2010a) and reduced household income (Cawley,
2004; Puhl and Brownell, 2001), the additional struggles due to loss of health and
income may in turn lead to an erosion of family cohesiveness and strength. Rising
rates of obesity also affect national security; U.S. military leaders have recently
described the role of obesity in reducing the pool of potential recruits to the armed
services (Christeson et al., 2010).
These human and societal consequences clearly justify action. Agreement is
now widespread that priority should be given to population-oriented preventive
approaches that can curb the development or exacerbation of excess weight gain
and obesity rather than to individual case finding and treatment. This applies not
only to children and adolescents, so that lifelong prevention can begin as early
as possible, but also to adults, among whom the health burdens of obesity are
greatest. Even without further growth in current levels of overweight and obesity,
future burdens of obesity-related illness, poor health, and quality of life will con-
tinue to grow significantly, as will the financial costs of health care for families,
employers, health care institutions, and the public.
OBESITY PREVALENCE AND TRENDS
The United States continues to experience an epidemic of overweight and
obesity that compels timely and effective action. Although obesity is not a new
problem, the percentage of people affected was relatively stable until the 1980s,
when it began to rise (NCHS, 2010). By adulthood, the prevalence of obesity is
approximately twice that observed during childhood, reflecting both the track-
ing of child and adolescent obesity into adult years and the new onset of obesity
as many adults experience gradual, progressive weight gain in their 20s, 30s, and
40s. Currently, a majority of U.S. adults and a substantial proportion of children
and adolescents have weight levels in the overweight or obese range.
Definitions of Overweight and Obesity
Definitions of overweight and obesity for children, adolescents, and adults
are provided in Box 2-2. According to these definitions, two-thirds of adult
Accelerating Progress in Obesity Prevention
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BOX 2-2
Definitions of Overweight and Obese
Adults
Overweight is defined as a body mass index (BMI) (a ratio of weight in
kilograms to the square of height in meters) of 25-29.9. Adults with a BMI of
30 or greater are considered obese. Among those who are obese, the increas-
ing health risks at higher levels of weight are sometimes indicated by further
classification into grades of increasing severity: grade 1 obesity is defined as
a BMI of 30 to 34.9, grade 2 is a BMI of 35.0 to 39.9, and grade 3 is a BMI of
40 or greater.
Children and Adolescents
Overweight and obesity are defined by cutoffs on sex- and age-specific
Centers for Disease Control and Prevention (CDC) BMI reference curves to
account for growth and maturation: overweight, including obesity, is defined as
a BMI at or above the 85th percentile; obesity is defined as a BMI at or above
the 95th percentile.
Americans are overweight or obese, and the proportion who are obese has more
than doubled since 1976-1980, when it was 15 percent (NCHS, 2011). Even more
stunning is the parallel phenomenon in adolescents aged 12 to 19, among whom
the 5 percent obesity prevalence of 1976-1980 has now more than tripled (NCHS,
2011). Figure 2-1 shows the consistent proportion of men and women in the over-
weight range (reflecting fewer people in the healthy weight range) but continu-
ing trends of increasing obesity during the most recent two decades. In men, the
prevalence of obesity increased by 13 percentage points from 1988 to 2008—from
19 percent to 32 percent—and doubled (from 5 percent to 11 percent) within the
grade 2 obesity category. In women, obesity prevalence increased by 10 percentage
points during the same period—from 25 percent to 35 percent—with a 7 percent-
age point increase in the grade 2 obesity category (from 11 percent to 18 percent)
(NCHS, 2011). Figure 2-2 shows the steady gradient of increasing obesity preva-
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Assessing the Current Situation
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vation does not apply evenly across all population subgroups and also may not
be sustained or lead to a lessening of the current high rate. Contributors to these
potential precursors of success must be identified and translated into approaches
for permanent change. Of greatest importance in this respect is that early signs of
success, even if real, not be misunderstood to be success. Success will occur once
population weight levels are in a healthy range. All of the adverse consequences—
human and economic—of the obesity epidemic described here are entrenched and
will continue to increase as children and adolescents on a course to become obese
mature. The next chapter of this report describes specific goals and strategies for
addressing obesity and examines practical and policy considerations relevant to
their implementation.
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