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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, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America 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. 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. 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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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distin- guished 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. Charles M. Vest 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 mat- ters 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 govern- ment 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 further- ing knowledge and advising the federal government. Functioning in accordance with general poli- cies 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. 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 xiii
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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 xiv
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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 xv Contents
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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 xvi