Summary and Final Remarks
This section summarizes final thoughts by Reynaldo Martorell and Jeffrey Koplan; the remarks are followed by a summary of the workshop as presented by Juan Rivera.
Martorell reminded the audience of the global nature of this epidemic and that developing intervention programs entail serious consideration to the unique context within each country. For example, in Mexico, the political situation will largely determine when and how a national plan for obesity prevention in children can be initiated. It is important that national surveys on obesity continue so they can serve to increase the awareness of the epidemic. The hope is that the new government will use the data as a basis in formulating its programs. In addition to a national plan in Mexico, Martorell supports a U.S.–Mexico binational collaboration in different areas involving government, academic institutions, industries, and nongovernmental organizations (NGOs). Collaborative exchanges on research indicators, monitoring, and program efficacy and evaluation will be useful. Mechanisms for collaborative training of human resources can ensure the continuity of initiatives. The joint search for funding resources will also be beneficial; Martorell also suggested forming a small group to design an action plan for identifying potential mechanisms and funding resources.
Koplan gave some comments on the workshop discussions, focusing on the role of industry and government. Koplan emphasized the importance of alliances between industry and other partners in both the United States and
Mexico and noted that these alliances need to be carefully crafted so that they are not perceived as being driven by industry’s interests and thus risk losing credibility. To develop and maintain public trust in the alliances’ initiatives he recommends that industry takes a participant’s role rather than a leadership role.
He reiterated the role of industry and noted that self-regulation continues to be a point of debate, but he commended the food industry on the many initiatives it already has undertaken. However, he indicated that additional questions need to be answered, such as those related to the definition of a healthy product by developing a standard label for healthier products or other mechanism. He suggested that industry has an even broader role as an advocate for all healthy lifestyle activities, for example, it could serve as an advocate for the Verb Campaign (see Appendix C for a description), whose U.S. government funding unfortunately was stopped because of priorities other than obesity prevention. One of Koplan’s concerns is that the U.S. government does not invest sufficiently in prevention in general and in obesity control in particular, and such investment is required to make real progress in obesity prevention.
Koplan concluded that the role of the media should include a coherent, coordinated commitment throughout all programming to deliver a message about exercise and diet that will have much more impact than a discrete health message. Different circumstances will require carefully crafted messages depending on the communication means; for example, the nature of a message from a public health authority should be different from a more creative health message embedded in a TV show.
Workshop discussions, noted Koplan, conveyed how the profound differences in systems and cultures between Mexico and the United States could serve as lessons and result in synergistic, greater collaborative opportunities among different sectors and countries.
Juan Rivera summarized workshop discussions in more detail. Rivera reiterated the goals of the workshop and presented obesity trends in the United States (see Figure 2-1), providing a clear picture of the increase in prevalence since the 1970s. The 2005 IOM report, Preventing Childhood Obesity: Health in the Balance, concluded that childhood obesity is an important public health problem, both in the United States and in Mexico and that Mexican–American children are among the most affected. The complexity of the problem might be augmented in the case of Mexican–American children because of the exchange of people across the borders and the potential consequences related to shifts in culture, language, food, media, economy, and trade. The 2005 IOM report provided an enlightening review of the implications for children and society and a set of recommendations for all sectors of society to be engaged and participate in the solutions. Such a review was critical as a basis for this workshop and served to under-
stand the nature of the problem, including risk factors. The key conclusions of the IOM report were that obesity in children is a nationwide health problem requiring a population-based prevention approach; the goal is energy balance (i.e., healthful eating behaviors and regular physical activity); society changes at all levels are needed; and multiple sectors and stakeholders should participate for programs to be successful. According to the report, a set of associated and interrelated factors play an important role in determining the energy balance and they relate to all sectors and disciplines (i.e., individuals, communities, and macrolevels); interventions at all of these levels will be the key to reversing the epidemic (see Figure 2-7, the ecological model of obesity).
In addition to the IOM report, an international framework for childhood obesity prevention was developed by the World Health Organization–Food and Agriculture Organization (WHO–FAO) through a group of experts as part of a broad task addressing diet, nutrition, and chronic disease prevention. The evidence on factors responsible for obesity were carefully evaluated and were the basis for the global strategy on diet, physical activity, and health approved by the World Health Assembly in 2004 (Mexico was a participant). Two other documents about obesity in Mexican and Mexican–American children and youth (see Appendixes B and C) were used as basis for the discussions in this meeting.
It is clear that obesity is a serious health problem in Mexico (see Figures 2-5 and 2-6). As in the United States, the obesity prevalence is growing for children under 5 years old (based on the trends in data from 1988 and 1999), and it is expected to grow even more. In addition, data from INSP show that children engage in physical activity for only one to two hours a day, but the time they spend watching television or playing videos is double that amount. Although the authors of the papers in the Appendix B found no published information from surveys regarding barriers against physical activity engagement among Mexican children, U.S. data suggest that barriers such as expense, transport, availability, and personal safety are more substantial in the Hispanic population than for whites or African Americans.
Dietary habits in Mexico have changed, where the consumption of meat, fruits, vegetables, and milk is giving way to an increased intake of refined carbohydrates, soda, and fats. For instance, as much as 56 percent of Mexican children consume fewer than 100 grams of fruit and vegetables per day, and only 8 percent consume the recommended amount of 400 grams per day. Interventions related to diet should focus on those factors that shape food and beverage consumption at different levels—policy making, marketing, product placement and price, cultural values, economic factors, public policies, production, distribution and promotion of food, individual and developmental factors, as well as those factors related to family
and home, school and peers, neighborhood, and community. The key stakeholders involved in any intervention are families, schools, communities, healthcare, industry, media, and government.
The roles of the various sectors were discussed by experts representing public and private sectors in Mexico and the United States. Participants discussed that among the public sector, the healthcare sector should assume responsibility for assuring a healthy environment by leading in the development of a national prevention plan and coordinating interventions with other relevant sectors. In addition, all stakeholders should participate in developing evidence-based regulations. Congress should enact legislation that creates a healthy environment and the appropriate government bodies should allocate funds for obesity prevention research.
Areas identified in discussions where the participation of the private sector would be of benefit are (1) forming public–private partnerships; (2) offering a broader range of healthier foods (those with less sodium, few calories, and reduced quantities of fat and trans fatty acids); (3) providing consumer information; (4) implementing marketing strategies that encourage children to make healthy choices; (5) engaging in advocacy and dialogue; and (6) funding research and sharing information, for example, market surveys data.
With regard to the role of the community, developing obesity prevention initiatives, especially those that involve youth participation, would be a critical component of an obesity prevention agenda. The school environment was recognized as needing significant improvements, and the community could play a role in this respect.
Rivera also summarized the discussions of the three working groups. Working group I examined common themes and factors by comparing the differences and similarities of obesity prevention between the United States and Mexico. The two countries differ in that Mexico, unlike the United States, is undergoing a drastic change in dietary habits as well as facing the double burden of under- and over-nutrition. However, as far as similarities, the group identified the following:
Childhood obesity is a major public health problem.
There is an urgent need for action at all levels.
The evidence on childhood obesity determinants is scarce.
Working Group II discussed data gaps and concluded that research is needed at all life stages. The following were general themes for a research agenda proposed by Working Group II:
Continued research on risk factors especially those related to behavior but also on the dietary habits, nutrient composition of food, and physi-
cal activity patterns that lead to obesity prevention and weight control. Potential mediator factors should also be investigated. Effective interventions that place special emphasis on motivation for health-related behaviors could also be pursued.
Research on evaluation of interventions on a macro level (e.g., evaluation of governmental policies and initiatives as well as of private-sector initiatives).
Working Group III explored actions implemented, opportunities, challenges, and barriers. The group concluded that although interventions are being implemented in many fronts, evaluations of the efficacy of the interventions are lacking. Unfortunately, there is also no sense of urgency and the public in general is unfamiliar with the economical and health consequences that obesity incurs. In addition, to reverse the perception that the task is too complex, multilevel and multifactorial interventions should be conducted in an environment of trust among the different sectors, including the public. A clear, detailed research agenda is also needed to promote evidence-based interventions.
The working group explored the opportunities for binational collaborative research and identified the importance of identifying binational funding mechanisms. A clear proposal evolved for the creation of an Obesity Prevention Task Force for Mexico in which the government has the leadership but also involves representatives of relevant stakeholders such as government, industry, civil society, and academia. An immediate goal of the task force would be to develop a national childhood obesity prevention plan that would include policies, norms, and regulations for preventing obesity; strategies for changing environmental conditions that promote obesity; communication plans for promoting behavioral change; and a plan for coordinating all of the proposed strategies. Mexico could draw from the U.S. experience and from the findings in the 2005 IOM report, Preventing Childhood Obesity: Health in the Balance. Additionally, results from the ENSANUT 2006 survey will demonstrate trends in obesity and could be used to increase awareness of the epidemic and to help foster a sense of urgency for action.
Binational collaborations could include sharing media-based health promotion content from radio, television, Internet, and printed media to reach Mexican and Mexican–American children; establishing guidelines for appropriate marketing targeted at children and youth; and sharing educational materials adapted for Mexican culture.
Furthermore, binational collaborations would be invaluable to (1) strengthen ongoing scientific research and programmatic exchanges; (2) compare survey findings; (3) exchange results from intervention evaluations; (4) share lessons from programs, strategies, and actions; (5) assist in
training human resources with new, appropriate skills, needed to address the epidemic; and (6) explore funding strategy mechanisms.
Mr. Secretary, please allow me to bridge protocol and start speaking in English so we can communicate better to our visitors from the States. I think a short introduction of Dr. Frenk will serve to help understand why it is that we feel a special privilege in Mexico in having people who come from academia move into the public sector as major decision makers; he is open and welcoming of this kind of workshop that provides the evidence. Dr. Frenk is an M.D. who also holds a Ph.D. from Michigan on healthcare organizations and sociology and in 1987 was the founding director of the National Institute of Public Health. We feel indeed that he is a member of the academic community. He is also a member of the IOM—as a foreign associate, we are not called members, we are foreign associates, it sounds distinguishing, actually. There is also a long-standing collaboration between IOM and Mexican institutions. Something like 13 years ago, Julio Frenk and Harvey Fineberg promoted an IOM–Mexican Academy of Medicine workshop on the impact of NAFTA (North American Free Trade Agreement) on our Health Services; we also had Canadian colleagues in that workshop, after which a report came out. That is just to tell you that there is a long-standing experience of collaboration with IOM and American universities on issues that are of common interest; and certainly childhood obesity is one of the largest health problems that we share.
The attitude from the main authorities of the health sector in Mexico toward evidence-based health policy is well established and, quite frankly, we feel proud about having had that not only with Julio but also with his predecessors; it is almost a quarter of a century of a tradition of having M.D.’s with Ph.D.’s very much into research and linking research results into health policy. It is going to be hard to shift.
The issue is that in the results of the National Nutrition Surveys, the first one in 1988, malnutrition was seen as the largest public health problem, but the obesity problem was increasing. Ten, eleven years later, with the second National Nutrition Survey, the obesity problem was discovered in all its magnitude, a problem that grew impressively, more than in the United States at any moment, and which turned on all the alarms. In 1999 and in 2000, when the results were made public, we remained with the alarms on, but nothing else happened. I think that the first necessary step was to have the information, but this is not enough, we have to move on to
public policies. In Mexico we have the big paradox of having women of reproductive age who are obese and anemic, and we have also another cruel paradox, that of obese parents and malnourished children. That is, I believe, unacceptable.
In Mexico we have managed to decrease a great deal of malnutrition in children with national programs against poverty. We have started to work on the deficiency of micronutrients when the other problem shows up, and we still have not done anything. If we will do an evaluation of it on the economic impact, along with the other riders of the apocalypses that accompany it—hypertension, cardiovascular disease, and diabetes—then I think that we will realize that these four riders are imposing big amounts of money in the public and private healthcare sectors and lots of suffering in human beings, of course. A better estimation of the economic costs of this salient epidemic still remains to be incorporated in the agenda so that we can realize the urgency of public and private investment to face this emergency. I believe that a conclusion derived from the studies from IOM, WHO, CDC, and others, is that one will never have all the evidence one would like to act upon, nevertheless, there is already enough evidence and successful experiences at local, state, and national levels of action that could have an impact. We have to acknowledge that, unlike vaccination programs or some other programs treating infectious diseases, the reward for the effort will take time. What we do now, will be seen, if we are lucky, in one or two decades, and for this reason it might not be attractive for politicians to take difficult measures, having confrontation, for something they will not see results in during their political lives; nevertheless, it is an absolute responsibility as government employees to start taking actions in this regard. Mr. Secretary, we have a good investment in information. Soon we will have the results from the National Health Survey; the nutrition part of the last seven states will soon be picked up, and in two months we will have preliminary results. I believe we can incorporate that information in order to take public political measures. I think that Juan Rivera, in his magnificent report, stated very clearly that there are several specific steps to take in the next few months that will lead us to leave a legacy from this administration, along with other legacies that it will leave, for those who will follow us. With this short summary and thanking again all our friends from IOM, Linda Meyers, Vivica Kraak, and Maria Oria and to those who participated in those brilliant reports from the IOM, many thanks. With their work they are saving us a huge amount of work; you have distilled scientific evidence for us, and we do not have to reinvent the wheel. Many of the policies, along with the evidence supporting them, will serve us to adapt and adopt some of the policies recommended there for the different sectors involved in this complex issue. Dr. Frenk, I would like to give you the floor.
I noticed that when Jaime spoke in Spanish more people put on headphones, the worrisome thing was that several of the Mexicans put on headphones, too. At that point I decided to vividly break with protocol and speak in English, very briefly because I know you are at the end of a long work session, and this is a beautiful city that you probably would enjoy visiting, this is the City of Eternal Spring. It is really a great pleasure, first of all to meet again many good friends who have come to this seminar, and as Jaime said, I am a member, at least we are called foreign and not alien, associates we should not go [inaudible] but I am one of the three foreign associates of the IOM in Mexico, Jaime is another one, so this is both an opportunity to participate in the activities of the Institute, to continue what has been an enriching series of exchanges that I keep with the Institute, and I want to thank Mauricio Hernández again for providing the venue where I can learn. Hopefully that helps me to do my job in a better manner. We continually have seminars at the Institute where the policy makers at the Ministry of Health come, and we meet for an afternoon like now and discuss lots of input on priority issues. Certainly the one you have chosen for this seminar is a top priority. It is a silent epidemic, probably one of the clearest examples of the double burden of disease and risk factors. The fact that we still have not completely overcome the traditional old scourges of malnutrition and yet, even though we have made a lot of progress but there are still pockets, among poor people, among indigenous populations. Without having completely overcome the old problems, we now face the problems of the wealthier societies in the world, and this is the nature of the epidemiological transition in countries like Mexico, that we are always faced with that double agenda. The meeting is very timely because we are very soon going to have the results of this major survey that will provide us a third point in time. If, as Juan was already anticipating, the results show a further deterioration of the situation in terms of obesity and overweight it is a great opportunity to raise public awareness and indeed in the face of the change of administration in seven months it could well be placed as a top priority for policy making in the health arena in the future.
This is the toughest of the issues, when one looks at sins representing emergent risks to health, the one dealing with food intake and the balance with exercise is by far the toughest. Tobacco is a black-and-white situation, even one puff is harmful. You do not have to discuss a lot, it is clearly a risk to health, and you can have very clear cut interventions: rising taxes, forbidding publicity, etc.; the policy package is clear cut because the risk is clear cut. Alcohol begins to get a little bit more complex because there are certain levels of consumption that are harmless and at some levels there is even benefit; still, alcohol is not vital for sustaining life. But when you come
to issues of nutrition then you are really into an area where the complex questions, by far, come because food is not only not harmful, not only beneficial, it is essential for sustaining life, so the issues become much more difficult, and I like the title of Jeff Koplan’s report, the balance, I mean. The question here is the search for balance but it makes the policy debate much more difficult; the same policy packages do not apply to each of these three areas of emerging risks: tobacco, alcohol consumption, and excessive or imbalance food intake. As I said, by far this is the most difficult one. This is probably a case where we absolutely need to have evidence-based policy; we run into the temptation of pointing fingers, of trying to identify villains, and breaking lines of communication and go for more ideological decisions rather than scientifically derived evidence, but we can really cause a lot of harm.
For me, this exercise that you have done for the last two days is a clear example of how do we better build that evidence base. Let me tell you, not the only example, there are many examples but this shows the value of making long-term capacity investments. This thing here did not exist 20 years ago, and it is taking 20 years to build not only the physical infrastructure but specially the human infrastructure to reach this capacity we now have, for example, to generate this high-quality survey; the Institute is constantly involved in providing evidence based in evaluating public policies and in Mexico, I think, this is a clear example of the need to do long-term investment on intellectual capital building in developing countries. It is countries like Mexico that need evidence based, even more than the richer countries. The fact that we can even at all have this discussion is a testimony of the wisdom of particularly Dr. Guillermo Soberon, who happens to be the third foreign associate of IOM in Mexico; when he was minister, 20 years ago, he decided to start this Institute of Public Health, and now we are ripening the fruits that were sowed some many, many years ago. I am very glad to see Enrique de la Madrid because his father was the president at that point and came here to dedicate the buildings and the laboratories for the Center for Infectious Diseases. At that point, Mexico was in a very serious economic shape, oil prices, contrary to what is happening now, have dropped, we were in the mist of a major financial crisis, and yet there was a government that has the vision to say, “You know, it is exactly when you are facing constraints of that sort that you need to invest in research.” I am very happy to see one more fruit of those seeds that were sowed then; we need that evidence to orient the policies that we have.
In the topic of obesity, we have two main policy instruments: the first is health protection, the other is health promotion. Health protection we interpreted as the set of tools to protect people from passive exposure to different risks, particularly regulatory mechanisms and health promotion to enhance or diminish exposure when that exposure is active. We need to use
those tools in a thoughtful manner; the first one is the stick and the other is the carrot. The first one is all the regulatory framework; we have done enormous efforts in this administration to modernize our agency that does a lot of the regulation. We used to have an area in the center bureaucracy of the Secretary responsible for generating risks regarding air pollution, water pollution, food contamination of various sorts, so we regulatory role for almost everything because almost everything can be a risk to health. Now we have an independent, autonomous agency, a little bit like the Food and Drug Administration, except it also has elements of the Environmental Protection Agency and Occupational Safety and Health Administration. We set standards for occupation and environmental exposures, although we do not enforce them but we do set the standards. It is a very important agency called Federal Commission for Protection against Health Risks, that is actually its name so we are emphasizing the concept of protection and the idea is protecting people from risks factors where exposure is passive. Just by breathing, one brings risks to health, or a very major passive exposure which is information for example to publicity, so through the action of that, for example, we have completely ban now publicity on tobacco; for issues of labeling and marketing, we can actually use that policy too. We have found great merit in frameworks for self-regulation. As you know Mexico has made a major transition towards full-fledged democracy, and we believe in collaborating with all social sectors. In fact, with many of the major industrial groups, including Con-Mexico, with Enrique de la Madrid, and the individual companies that form it, we are trying to create a framework that is based on collaboration. The value of self-regulation is that it is not a soft government because self-regulation is based on trust and those that engage in self-regulation know that if the trust if bridged, then the response from the government has to be even tougher than pure regulation. That has been our philosophy and it has worked on a number of arenas.
The other policy instrument that we have is health promotion, to enhance people’s capacity to reduce their exposures, empower people to reduce their exposures where the exposure is active, as a function of choices that are made and behaviors that are engaged. Here, of course, our great tool is health promotion, just a couple of things that have happened, a whole new Official Mexican Norm (Norma Oficial Mexicana), in Mexico we have a standard-setting approach for a number of areas that have to be participatory. It took us almost four years of dialog, with all the actors, the research community, the NGOs, the activists, industry, and we finally came up with a new standard for nutritional orientation, and I would like to encourage the National Institute and maybe in this collaboration to actually begin thinking on an evaluative research on what happens; we did four years of huge process investment because these things get published, then all social groups can send comments, any kind of comment; once it has been
commented on, all those comments are processed, every single comment has to be responded. In this case, this was probably, from the many standards that we issue, the one that generated the largest amount of interaction with society. I think we finally have come up with the didactic tool, which is the nutritional dish, no longer the pyramid but the dish, which emphasizes the idea of balance and so forth; but we should monitor what happens because once you put that out if behavior does not change, it ends up being just one more document; this will not be good.
The other big initiative has been a program with the Ministry of Education, which we call Healthy Education, and that by the way has the participation of two private philanthropies: Banamex and Fundación Arronte. We have formed a special fund to promote health-promoting activities in schools, including now tobacco- and smoke-free schools, and part of the issues, there is nutritional attention, improving the nutritional quality of the food sold in the schools. Those are a few of the things, but I think we have a long way to go, particularly on the health promotion, which is actually the toughest part because it involves changing perceptions, changing behaviors, and part of the problem of the perception, is the risk perception, the fact that people tend to have very distorted assessments of relative risks.
A new instrument that we will develop is a new initiative that is called Take Measures, in the double sense of measuring your waist and then taking some measures in your life; we are distributing this paper strip to measure your waist and then it has different colors. If you are in the red you really ought to begin thinking about what you eat and how much exercise you do. But this is, I think, a long road ahead and particularly, shifting the perception of the population is going to be our biggest challenge. This is why, concluding, I really welcome the international collaboration, this is a field where obviously the epidemic of obesity is very much linked to forces of globalization, in fact some people have spoken of this new concept of globesity, meaning linking obesity to globalization, globesity, so the answer of global problems has to be global solutions and the best tool we have in global solutions is cooperation, dialog. I firmly believe we need to create knowledge-based international public good research, and I am very happy to see that there is a research agenda, but then also what Jaime said, the constant point is that, well you have just enough evidence, and you have to continue building the research evidence doing a lot of evaluative research to see if what you are doing is actually working. We need processes to share learning lessons. We were just talking with Jeff, can Mexico take the leap? Are we condemned to follow the same path of the non-Hispanic Whites or other populations in the United States? Can we learn something for Mexican-origin populations in the United States and here? Is there a way of, by engaging in a process of learning what regulatory measures or health promotion measures would avoid us the
pain? We have done that on tobacco. We do not have to go through the same set of steps before we act, but as I said before, this is a much more complex area, it has much more cultural underpinnings, societal underpinnings, but I believe we should do learn from each other to adapt and adopt what has proven to work in other countries, what is obviously culturally, financially, feasible in our country.
The other reason for welcoming this collaboration is of course the huge interdependence of Mexico and the United States; Hispanics are now the largest minority in the United States, and Mexicans are the largest group within the Hispanic population. There is clearly a convergence, we recently had in Cancun the meeting of President Bush, President Fox, and Prime Minister Harper from Canada. There is a whole new initiative call—The Safety and Prosperity Initiative for North America—that has an explicit component of converging standards in regulatory frameworks, and we have clearly a movement towards greater convergence and I think we ought to take advantage of it.
The idea of a joint task force is very appealing, we have had a very good history of successfully initiatives between Mexico and the United States. One that has been extremely successful has been the Binational Health Weeks. I had the chance to talk during lunch, I know they had to leave, both, with Diana Bonta and Xochitl Castaneda, which have been very instrumental; in 2001 we have had a week in October, perfectly synchronized between Mexico and the United States for a great number of health promotion activities. Last year was the fourth year we have done Binational Health Weeks and it was present in 33 states of the United States, 33 Mexican states, and now it is even in two provinces of Canada as well. The Binational Health Week has become a great venue, it has been very successful, if we can do this joint task force that would be very good, and if a concrete product is to leave this national plan, in addition to the first steps that have been taken by this administration and previous administrations, can be carried forward, I think that would be very helpful.
Every road, even the longest road has a first step, we have to take that first step, and I think with the work that you have done in this past couple of days we are better equipped to look forward to that step. Health has the great virtue of being a unifying value. Even though sometimes we do not have a very comfortable relation with our neighbors, partners, and friends in the United States we have always found that health matters are a way of really bridging the two societies. I think this could be yet another successful example of binational collaboration if the IOM in the United States, which has had a great history of collaboration with Mexico particularly with its current president Harvey Fineberg, and this National Institute of Public Health here as a great center for analysis, reflection, research, data, can build this bridge and combine all the actors, certainly on the Mexican
side, industry, NGOs, the other academic institutions. I think we could be on the path of taking very helpful measures for the Mexican population both here and in the United States and in that way pursuing the health of both countries.
Let me finish by thanking each and everyone, especially those of you who have traveled to come to Cuernavaca for this seminar. I can see from the wealth of conclusions that it has been a very fruitful time. I will do whatever I can do in the remaining seven months of this administration to support this work. Seven months is a lot of time, we can do a lot of things; no one in the Ministry of Health is packing, we do not feel like we are leaving, maybe it is a distorted self-perception, but we are feeling with the same energy as on day one; so you can be assured that the value of knowing that you have a deadline is that then the sense of urgency is even more pressing. We have seven months to deliver a high-quality product; let us take that first step on the long road. Thank you to everyone for having contributed to this joint enterprise.
IOM (Institute of Medicine). 2005. Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Academies Press.