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Committee on Accelerating Progress in Obesity Prevention
Food and Nutrition Board
Dan Glickman, Lynn Parker, Leslie J. Sim,
Heather Del Valle Cook, and Emily Ann Miller, Editors
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW 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.
This study was supported by Grant No. 61747 between the National Academy of Sciences and
the Robert Wood Johnson Foundation and a grant between the National Academy of Sciences and
the Michael & Susan Dell Foundation. Any opinions, findings, conclusions, or recommendations
expressed in this publication are those of the author(s) and do not necessarily reflect the view of the
organizations or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Accelerating Progress in Obesity Prevention.
Accelerating progress in obesity prevention: Solving the weight of the nation / Committee on
Accelerating Progress in Obesity Prevention, Food and Nutrition Board, Institute of Medicine of the
National Academies ; Dan Glickman . . . [et al.], editors.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-309-22154-2 (pbk.) — ISBN 978-0-309-22155-9 (e-ISBN)
I. Glickman, Dan. II. Title.
[DNLM: 1. Obesity—prevention & control—United States. 2. Environment Design—United States.
3. Needs Assessment—United States. 4. Program Development—United States. WD 210]
362.1963′98—dc23
2012007112
Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW,
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Copyright 2012 by the National Academy of Sciences. All rights reserved.
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WEIGHT OF THE NATION is a trademark owned by the U.S. Department of Health and Human
Services (DHHS/CDC). Use of this trademark is not an endorsement by DHHS/CDC of a particular
company or organization.
Cover photo credits: yellow squash (first column, first row) by DC Central Condition; people running
up stairs (fourth column, second row) by Osman Meran; man pushing a stroller on the beach (fifth
column, second row) by Michael L. Baird; watermelon (first column, fifth row) by Patrick Feller.
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of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2012. Accelerating Progress in Obesity Prevention:
Solving the Weight of the Nation. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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COMMITTEE ON ACCELERATING PROGRESS
I N OBESITY PREVENTION
DANIEL R. GLICKMAN (Chair), Executive Director of Congressional
Programs, The Aspen Institute, Washington, DC
M. R. C. GREENWOOD (Vice Chair), President, University of Hawaii System,
Honolulu
WILLIAM PURCELL, III (Vice Chair), Attorney at Law, Nashville, Tennessee
DAVID V. B. BRITT, Retired President and Chief Executive Officer, Sesame
Workshop, Fernandina Beach, Florida
JAMIE F. CHRIQUI, Senior Research Scientist, Health Policy Center, Institute
for Health Research and Policy, University of Illinois at Chicago
PATRICIA CRAWFORD, Director of Dr. Robert C. and Veronica Atkins
Center for Weight and Health and Cooperative Extension Specialist and
Adjunct Professor for the School of Public Health, University of California,
Berkeley
CHRISTINA ECONOMOS, New Balance Chair in Childhood Nutrition,
Friedman School of Nutrition, Science, and Policy, Tufts University, Boston,
Massachusetts
SANDRA G. HASSINK, Director, Nemours Pediatric Obesity Initiative,
Alfred I. duPont Hospital for Children, Wilmington, Delaware
ANTHONY B. ITON, Senior Vice President, Healthy Communities, The
California Endowment, Oakland, California
STEVEN H. KELDER, Beth Toby Grossman Distinguished Professor in
Spirituality and Healing; CoDirector, Michael & Susan Dell Center for
Healthy Living, University of Texas School of Public Health, Austin
Regional Campus
HAROLD W. (BILL) KOHL, III, Professor, Epidemiology and Kinesiology,
University of Texas Health Science Center-Houston, School of Public
Health, Michael & Susan Dell Center for Healthy Living, University of
Texas at Austin
SHIRIKI K. KUMANYIKA, Professor of Epidemiology and Associate Dean
for Health Promotion and Disease Prevention, University of Pennsylvania
School of Medicine, Philadelphia
PHILIP A. MARINEAU, Operating Partner, LNK Partners, San Francisco,
California
VICTORIA RIDEOUT, President, VJR Consulting, San Francisco, California
v
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EDUARDO J. SANCHEZ, Vice President and Chief Medical Officer, Blue
Cross and Blue Shield of Texas, Richardson
ELLEN WARTELLA, Al-thani Professor of Communication, Professor of
Psychology and Professor of Human Development and Social Policy,
Director of the Center on Media and Human Development at Northwestern
University, Evanston, Illinois
Study Staff
LYNN PARKER, Scholar
LESLIE J. SIM, Senior Program Officer
HEATHER DEL VALLE COOK, Program Officer
EMILY ANN MILLER, Associate Program Officer
HEATHER BREINER, Research Associate
MATTHEW B. SPEAR, Program Associate (until July 2011)
ELENA OVAITT, Senior Program Assistant (from September 2011)
LAMIS JOMAA, Christine Mirzayan Science & Technology Policy Graduate
Fellow (until December 2010)
ANTON L. BANDY, Financial Associate
GERALDINE KENNEDO, Administrative Assistant
LINDA D. MEYERS, Director, Food and Nutrition Board
vi
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Reviewers
T his 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 pos-
sible 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:
Jenna Anding, Texas A&M University
Leann L. Birch, Pennsylvania State University
John C. Cawley, Cornell University
Lilian Cheung, Harvard University
Antonio Convit, New York University School of Medicine
Lori Dorfman, Berkeley Media Studies Group
John R. Finnegan, Jr., University of Minnesota School of Public Health
Vincent Fonseca, Texas Department of State Health Services
Wally Gomaa, ACAP Health
W. Philip T. James, International Association for the Study of Obesity
Christine M. Olson, Cornell University
Tom Robinson, Stanford University School of Medicine
Kate Rogers, H-E-B Stores
Robert Sege, Boston Medical Center
Dianne Stanton Ward, University of North Carolina at Chapel Hill
Derek Yach, PepsiCo., Inc.
vii
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Although the reviewers listed above have provided many constructive com-
ments and suggestions, they were not asked to endorse the report’s 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
and Enriqueta C. Bond, Burroughs Wellcome Fund. Appointed by the National
Research Council and Institute of Medicine, they were responsible for making
certain that an independent examination of this report was carried out in accor-
dance 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.
Reviewers
viii
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Preface
O besity is a public health issue of monumental importance to the nation. I
would argue that it is the most significant public health challenge we face at
this time, both because of the huge number of people it affects and because of the
ripple effects it has and will have on the development of debilitating and costly
chronic diseases. Obesity is a major contributor to the health care cost challenges
we confront today in the United States. These costs have the potential to become
catastrophic and unaffordable unless all sectors of society take the need for obe-
sity prevention seriously and act responsibly. It is untenable to wait any longer
until people are already sick, requiring that most of our efforts and funding be
devoted to crisis intervention for diseases that could have been prevented or made
less severe.
This report is part of a series of publications dedicated to providing accessible
and useful information and analysis to policy makers and others working to turn
the obesity epidemic around. Funded by the Robert Wood Johnson Foundation
(and the Michael & Susan Dell Foundation for the committee’s workshop and
workshop report on measurement issues in obesity prevention), this report focuses
on the areas of obesity prevention that are most important to pursue now to sig-
nificantly accelerate progress against the epidemic. The committee reviewed the
hundreds of recommendations that have been made related to obesity prevention,
the evidence that supports them, and the progress that has been made in their
implementation. I have become convinced through this process that the health of
the nation and its children is inextricably linked to a complex web of influences
on physical activity and diet. This truth must be communicated to individuals,
families, communities, and the broader U.S. society so they can understand the
nature of the threat and the multisector solutions that, working together, can
make a real difference. We need to reach many different kinds of people with
diverse interests and concerns—individuals moving through their daily lives
ix
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unaware of these issues, policy makers and others who make decisions that con-
trol physical activity and food environments, health care providers, the education
community, and the business community/private sector. We also must ensure that
individuals, families, and communities are empowered to work for change so their
environment will support them in their efforts to achieve and maintain a healthy
weight. We all need to maintain our commitment to progress and acceleration in
the areas that can make the most difference.
The committee has many people to thank for their support in developing this
report and its recommendations. We begin by thanking in particular Laura Leviton
and James Marks from the Robert Wood Johnson Foundation and Aliya Hussaini
from the Michael & Susan Dell Foundation for their encouragement.
We appreciate the extensive contributions of Ross Hammond, who was com-
missioned to provide technical insight into integrating, developing, and using
systems mapping techniques to inform our deliberations and decisions. His insight
and expertise added to the quality of our decisions and helped visually commu-
nicate the dynamic nature of the relationships we were considering and how they
fit within the greater societal context. We also thank Eric Olsen from Feeding
America for his important input as an unpaid consultant.
In addition, we want to express our gratitude to Shari Cookson, Nick Doob,
John Hoffman, Ali Moss, and Sarah Teale from Home Box Office (HBO)
Documentary Films for their contributions as unpaid consultants. These film
producers drew inspiration and guidance from our work and discussions for a
series of documentaries on obesity prevention that, along with the release of the
recommendations in this report, will serve as the foundation for a major national
public health campaign on obesity prevention. This campaign will be coordinated
by HBO and the Institute of Medicine (IOM) in association with the Centers for
Disease Control and Prevention, Kaiser Permanente, the Michael & Susan Dell
Foundation, and the National Institutes of Health.
The committee greatly benefited from the opportunity for discussion with the
individuals who made presentations at and attended our workshops and meetings.
(See Appendix C for a list of workshop and panel presentations.) We would
also like to thank Preston Maring and Ray Baxter from Kaiser Permanente, as
well as Martha Coven from the Domestic Policy Council and Rogan Kersh from
Columbia University, for their presentations. The experience and insights of all
these speakers contributed immeasurably to our deliberations.
I want to express my sincere appreciation and thanks to the committee mem-
bers for their extraordinary volunteer efforts in the development of this report. A
Preface
x
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special thank you goes to Bill Purcell and M. R. C. Greenwood for their impor-
Purcell impor-
tant role as vice chairs of the committee. Bill brought his immense experience as
a public servant in government to the task and M. R. C. her vast knowledge of
nutrition.
The committee could not have done its work without the outstanding
guidance and support provided by the IOM staff: Lynn Parker and Leslie Sim,
co-study directors; Heather Del Valle Cook, program officer; Emily Ann Miller,
associate program officer; Heather Breiner, research associate; Elena Ovaitt, senior
program assistant; and Lamis Jomaa, Christine Mirzayan Science & Technology
Policy Fellow. Matthew Spear also provided highly skilled logistical support.
Linda Meyers’ guidance and counsel were invaluable throughout our delibera-
tions. In addition, we are indebted to others throughout the IOM’s office of
reports and communications who patiently worked with us throughout external
review, revisions of this report and report briefs, and the production process
through final publication. They include Laura DeStefano, IOM report production
manager; Vilija Teel, IOM report review manager; and Lauren Tobias, IOM com-
munications director. And last but not least, the report greatly benefited from the
copyediting skills of Rona Briere.
Daniel R. Glickman, Chair
Committee on Accelerating Progress in Obesity Prevention
xi
Preface
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Contents
SUMMARY 1
1 THE VISION 17
A Systems Perspective, 21
Levels of Engagement to Mobilize Change, 22
Leadership, 27
The Issue of Responsibility, 27
Overview of the Report, 28
References, 29
2 ASSESSING THE CURRENT SITUATION 33
Human and Societal Consequences of the Obesity Epidemic, 34
Obesity Prevalence and Trends, 42
Contributory Trends, 47
Advances During the Past Decade and Barriers to Further Progress, 55
Tracking Progress on Outcomes, 64
Conclusion, 67
References, 68
3 GOALS, TARGETS, AND STRATEGIES FOR CHANGE 79
Goals of Obesity Prevention, 80
Targets for Behavioral and Environmental Change, 84
A Comprehensive and Integrated Approach to Preventing and Addressing
Obesity, 89
A Successful Model of Comprehensive Change, 92
Practical and Policy Considerations, 97
Tracking Progress in the Change Process, 106
Conclusion, 107
References, 108
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4 STUDY APPROACH 115
The Committee’s General Approach, 117
Assessment of Progress, 122
Summary, 126
Reference, 126
5 PHYSICAL ACTIVITY ENVIRONMENTS 127
Recommendation 1, 130
Strategies and Actions for Implementation, 135
Strategy 1-1: Enhance the Physical and Built Environment, 135
Strategy 1-2: Provide and Support Community Programs Designed to
Increase Physical Activity, 139
Strategy 1-3: Adopt Physical Activity Requirements for Licensed Child
Care Providers, 142
Strategy 1-4: Provide Support for the Science and Practice of Physical
Activity, 145
Integration of Strategies for Accelerating Progress in Obesity Prevention, 148
References, 148
6 FOOD AND BEVERAGE ENVIRONMENTS 153
Recommendation 2, 162
Strategies and Actions for Implementation, 166
Strategy 2-1: Adopt Policies and Implement Practices to Reduce
Overconsumption of Sugar-Sweetened Beverages, 166
Strategy 2-2: Increase the Availability of Lower-Calorie and Healthier
Food and Beverage Options for Children in Restaurants, 184
Strategy 2-3: Utilize Strong Nutritional Standards for all Foods and
Beverages Sold or Provided Through the Government, and
Ensure That These Healthy Options Are Available in All
Places Frequented by the Public, 190
Strategy 2-4: Introduce, Modify, and Utilize Health-Promoting Food and
Beverage Retailing and Distribution Policies, 201
Strategy 2-5: Broaden the Examination and Development of U.S.
Agriculture Policy and Research to Include Implications for
the American Diet, 207
Integration of Strategies for Accelerating Progress in Obesity Prevention, 217
References, 218
Contents
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7 MESSAGE ENVIRONMENTS 235
Recommendation 3, 240
Strategies and Actions for Implementation, 241
Strategy 3-1: Develop and Support a Sustained, Targeted Physical Activity
and Nutrition Social Marketing Program, 241
Strategy 3-2: Implement Common Standards for Marketing Foods and
Beverages to Children and Adolescents, 249
Strategy 3-3: Ensure Consistent Nutrition Labeling for the Front of
Packages, Retail Store Shelves, and Menus and Menu Boards
That Encourages Healthier Food Choices, 257
Strategy 3-4: Adopt Consistent Nutrition Education Policies for Federal
Programs with Nutrition Education Components, 263
Integration of Strategies for Accelerating Progress in Obesity Prevention, 272
References, 272
8 HEALTH CARE AND WORK ENVIRONMENTS 285
Recommendation 4, 289
Strategies and Actions for Implementation, 289
Strategy 4-1: Provide Standardized Care and Advocate for Healthy
Community Environments, 289
Strategy 4-2: Ensure Coverage of, Access to, and Incentives for Routine
Obesity Prevention, Screening, Diagnosis, and Treatment,
299
Strategy 4-3: Encourage Active Living and Healthy Eating at Work, 303
Strategy 4-4: Encourage Healthy Weight Gain During Pregnancy
and Breastfeeding, and Promote Breastfeeding-Friendly
Environments, 308
Integration of Strategies for Accelerating Progress in Obesity Prevention, 318
References, 318
9 SCHOOL ENVIRONMENTS 329
Recommendation 5, 334
Strategies and Actions for Implementation, 336
Strategy 5-1: Require Quality Physical Education and Opportunities for
Physical Activity in Schools, 336
Strategy 5-2: Ensure Strong Nutritional Standards for All Foods and
Beverages Sold or Provided Through Schools, 343
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Strategy 5-3: Ensure Food Literacy, Including Skill Development, in
Schools, 357
Integration of Strategies for Accelerating Progress in Obesity Prevention, 365
References, 368
10 ANSWERING QUESTIONS ABOUT LEADERSHIP, PRIORITIZATION,
AND ASSESSMENT WITH A SYSTEMS PERSPECTIVE 379
Defining Leadership and Identifying Leaders, 382
Implementation, 383
Priorities, 384
The Public Health Crisis as Motivator and Catalyst for Implementation, 385
Assessment of Progress, 386
Looking to the Future: Moving to the Next Level of Systems Analysis, 388
References, 391
APPENDIXES
A Acronyms and Glossary 393
B Methodology: Development of the Committee’s Recommendations 407
C The Committee’s Recommendations, Strategies, and Action Steps 427
D Workshop and Panel Public Sessions 447
E Committee Member Biographical Sketches 453
Contents
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