WORKSHOP IN BRIEF FEBRUARY 2014
INSTITUTE OF MEDICINE
Advising the nation • Improving health
The Current State of Obesity Solutions in the United States—Workshop in Brief
The Current Opportunity
For the first time in decades, promising news has emerged from efforts to stem the epidemic of increasing weight that has gripped the United States in recent years. Obesity rates among low-income preschool children have undergone significant decreases in 18 states. Obesity appears to have plateaued among girls, regardless of ethnicity, although it continues to increase among men and boys, and among African American and Mexican American women. According to William Dietz, formerly of the Centers for Disease Control and Prevention (CDC) and now a consultant for IOM’s Roundtable on Obesity Solutions, these data suggest that the prevalence of obesity
could mirror the prevalence of smoking in the United States, for which awareness of adverse health effects and a multifaceted, multisectoral campaign led to significant decreases in smoking rates.
The next few years will be pivotal. Interventions that have proven effective on a small scale may need to be greatly expanded and strategies may need to span all levels of social organization, from individuals, families, and social groups to communities, businesses, and governments, said Dietz. In addition, as Dietz noted, rates of severe obesity continue to increase in the United States, which requires that clinical approaches be added to initiatives aimed at prevention.
Early Care and Education
Efforts to augment nutrition and physical activity have been growing rapidly in early care and education. Licensing, regulation, quality-rating and quality-improvement systems, new tools, and voluntary programs are among the Spectrum of Opportunities to create healthy environments for children developed by CDC for obesity prevention in early care and education. Debbie Chang of Nemours Foundation: A Children’s Health System said that particular attention is needed in the area of physical activity for children between birth and age 2 in family or home childcare settings, as well as a focus on disparities.
Written policies and regulations in all states, not just some, would help sustain such efforts, said Chang, as would integration of early care and education with the public health and child health systems. In addition, the provision of education, training, tools, and other kinds of support to providers of child care and early education could extend progress. A breakthrough action, said Chang, would be to strengthen the linkages between providers and families. Recognizing shared goals would enable parents and providers to work together rather than at cross purposes, creating a strong shared voice for children and cutting through barriers that have previously impeded opportunities to achieve healthy outcomes.
Dianne Ward of the University of North Carolina suggested regular monitoring of nutrition and physical activity policies and practices and the licensing of early care and education settings in all states, with support and coordination provided by the U.S Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS). More precise and timely information about current policies and practices could inform federal and state guidelines for obesity prevention. Ward also noted the advantages of providing a standard message about the type of physical activity that should be provided for infants, toddlers, and preschoolers in organized child care.
The Healthy, Hunger-Free Kids Act of 2010 contains several provisions designed to improve the Child and Adult Care Food Program (CACFP), observed Geri Henchy of the Food Research and Action Center. Evolving nutrition standards and implementation of the nutrition education requirement under the act provide a superb opportunity to improve the health of millions of children while reducing disparities among groups.
The evidence about what works in school-based obesity prevention efforts has grown dramatically during the past decade, said Sarah Lee of CDC. This evidence has resulted in guidelines, recommendations, and programs that have improved students’ health with a net savings in overall education and health costs.
Further research could illuminate many questions that remain unanswered, including the best ways to implement and evaluate multicomponent strategies and the nature of the link between education disparities and health disparities. Continued attention to translation, dissemination, and diffusion could increase the uptake and sustainability of evidence-based tools, resources, and professional development for diverse school communities. Lee stated that better communication and messaging could make the evidence regarding effective programs, policies, and practices more widely known and more widely applied. And strong policies at the federal, state, and local levels could be the breakthrough action that dramatically changes the landscape of nutrition and physical activity in all schools.
Christina Economos of ChildObesity 180 at Tufts University emphasized the strong link between physical activity and improved academic focus and behavior. Designating physical education as a core subject in schools, as recommended by the IOM report Educating the Student Body: Taking Physical Activity and Physical Education to School, could reverse the erosion of physical education in the curriculum. Also, advocates and policy makers could make better use of the grassroots innovations emerging from individual schools and of champions at the community level, including teachers, physical activity educators, administrators, parents, nurses, and cafeteria workers.
Jessica Donze-Black of the Pew Charitable Trusts emphasized nutrition issues, noting that children consume as much as half their calories in schools and that changes in schools have already produced remarkable improvements in health. Policies at all levels to ensure that every food sold to a child in school is a healthy food could greatly extend progress. Implementing such policies would require equipment, technical assistance and training, school–community collaborations, and adequate resources, but doing so could foster in children a healthy eating lifestyle for the rest of their lives, said Donze-Black.
Worksites can have a powerful influence, not just on the workers at the site but also on the customers and businesses associated with the site. For example, the Hy-Vee grocery chain in the upper Midwest has instituted a multifaceted campaign that blends services for its employees with services for its customers while bringing these programs to scale at the community level, said Helen Eddy, Hy-Vee’s assistant vice president for health and wellness. The company provides access to information and to health professionals, healthy eating classes and coaching, outreach to the community, and services to small businesses that lack the resources to provide their own worksite wellness programming. These efforts have helped reduce insurance costs for the company to an average of only $6,400 per employee per year, compared with a national average of $10,000–$12,000.
Employers have a very wide range of options to improve health, said Julia Halberg of General Mills, such as subsidizing healthy foods and providing onsite fitness centers, pumping rooms for breastfeeding women, treadmill working stations, preventive health services, and lessons in resiliency and stress management. Nico Pronk of HealthPartners cited efforts to counteract the sedentary nature of modern work and increased access to fruits and vegetables. In one corporate cafeteria, for example, a reduction in the price of salad bar purchases more than tripled salad bar sales.
Both health care providers and patients need education and training in the prevention and treatment of obesity, said Don Bradley of Blue Cross and Blue Shield of North Carolina. Furthermore, providers include not just physicians and nurses but family members, childcare providers, teachers, pharmacists, insurers, and policy makers. It takes a village to prevent and treat obesity, he said.
Many health care providers are not prepared to have the delicate and complicated conversations needed to change behaviors in overweight and obese patients, noted Loel Solomon of Kaiser Permanente. Online training for providers is one way to disseminate widely the skills and knowledge needed for productive conversations. Training also can help providers connect their patients to community-based resources.
The medical care system is just part of a much larger health system, added Eduardo Sanchez of the American Heart Association. Reforms of the reimbursement system could support change in this larger system, along with evidence-based, community-integrated, family-centered interventions.
Communities and States
Reflecting the systems nature of obesity prevention and treatment, an increasing number of mayors and other elected officials recognize the economic value of healthy communities, said Leon Andrews of the National League of Cities. These officials have a unique ability to bring a very wide range of stakeholders into conversations that can yield comprehensive strategies to improve health. These strategies can be universal in their objectives but targeted in their approach to reach the groups that most need help.
As an example of comprehensive and coordinated strategies, Cheryl Bartlett, Commissioner of the Massachusetts Department of Public Health, outlined a statewide effort to use body mass index screening for students, school nutrition regulations, public information campaigns, municipal wellness grants, farmers’ market programs, safe sidewalks and lighting, and a wide range of other steps to reduce the prevalence of obesity and improve the health of state residents. And, in California, observed Marion Standish of The California Endowment, policies that are scalable and enforceable and promote community engagement are building momentum to change the course of the epidemic.
The Federal Government
Kevin Concannon, Under Secretary for Food, Nutrition, and Consumer Services at USDA and Howard Koh, Assistant Secretary for Health at HHS, reviewed some of the many federal programs that can contribute to reducing obesity rates in the United States. The Special Supplemental Nutrition Program for Women, Infants, and Children, CACFP, the Supplemental Nutrition Assistance Program, the HealthierUS School Challenge, and initiatives established under the Healthy, Hunger-Free Kids Act of 2010 all have provisions designed to improve the nutritional quality of what Americans eat. The Physical Activity Guidelines for Americans, the work of the President’s Council on Fitness, Sports, & Nutrition, the Presidential Youth Fitness Program, the Let’s Move programs, Community Transformation Grants, and the public health and prevention provisions of the Affordable Care Act are all helping to increase physical activity among children and adults. Although much remains to be done, said Koh, these programs collectively have had a major impact.
Federal actions are helping to change the health care system, said Jeff Levi of the Trust for America’s Health. As the health care sector redirects its attention to outcomes and the social determinants of health, obesity prevention and control can be emphasized. In addition, greater collaboration and strategic funding among federal agencies can leverage available resources to change the community environments that shape nutrition and physical activity.
Business and Industry
Through initiatives such as the Healthy Weight Commitment Foundation and the Partnership for a Healthier America, food and beverage companies have been removing calories from the marketplace, selling fewer calories, and reducing the amount of calories Americans consume. At the same time, they have continued to profit—a recent study found that lower-calorie products drove 82 percent of the sales growth among food and beverage companies that were part of the Healthy Weight Commitment Foundation. In other words, said the foundation’s Lisa Gable, selling lower-calorie foods and beverages is just good business.
Companies can provide business processes and expertise to the obesity reduction programs of nonprofits, schools, churches, and other organizations, Gable observed, yielding sustainable, integrated systems that operate in a cost-effective manner. Companies also have invested in sophisticated, highly flexible communication techniques with mature channels that could be used to deliver information to those with the greatest need.
The climate for business and industry is different today than it was just 5 years ago, added Larry Soler of the Partnership for a Healthier America. A growing foundation of trust is facilitating the development of public–private partnerships focused on health and wellness. These partnerships are producing change in stores, communities, childcare centers, schools, homes, hospitals, and other settings. Meaningful change requires continued and multifaceted efforts, said Soler, but if these efforts are sustained, progress will continue.
A very wide range of actions can influence the prevalence of obesity, said Bill Purcell, chair of the IOM Roundtable on Obesity Solutions, in his closing remarks at the workshop. The challenge is not so much knowing what do to but figuring out how to do it.
The roundtable is uniquely positioned, because of the breadth of its expertise, to take the knowledge base that exists today and apply it to the goal of preventing and treating obesity. As Harvey Fineberg, president of the IOM, stated, the roundtable is dedicated to “the basic proposition that we, working together, can reduce obesity in the United States.”
Roundtable on Obesity Solutions
Bill Purcell III (Chair)
Jones Hawkins & Farmer, PLC, Nashville, TN
Russell R. Pate (Vice Chair)
University of South Carolina, Columbia
Mary T. Story (Vice Chair)
Duke University, Durham, NC
American Associaton of School Administrators, Alexandria, VA
Nelson G. Almeida
Kellogg Company, Battle Creek, MI
National League of Cities, Washington, DC
National Association for the Advancement of Colored People, Baltimore, MD
Heidi Michels Blanck
Centers for Disease Control and Prevention, Atlanta, GA
Don W. Bradley
Blue Cross and Blue Shield of North Carolina, Durham
Cedric X. Bryant
American Council on Exercise, San Diego, CA
Debbie I. Chang
Nemours Foundation, Newark, DE
Highmark, Inc., Pittsburgh, PA
Congressional Hunger Center, Washington, DC
Bonnie C. DeVinney
Greater Rochester Health Foundation, Rochester, NY
Tufts University, Boston, MA
David D. Fukuzawa
The Kresge Foundation, Troy, MI
Healthy Weight Commitment Foundation, Washington, DC
Nestlé USA, Glendale, CA
Sandra G. Hassink
American Academy for Pediatrics, Wilmington, DE
Kitty Hsu Dana
United Way Worldwide, Alexandria, VA
Scott I. Kahan
STOP Obesity Alliance, Washington, DC
University of Pennsylvania, Philadelphia
Mars, Inc., Germantown, MD
The Obesity Society, Pittsburgh, PA
Bipartisan Policy Center, Washington, DC
Canadian Institutes of Health Research, Toronto, ON
Linda D. Meyers
American Society for Nutrition, Bethesda, MD
H. Melvin Ming
Sesame Workshop, New York, NY
YMCA of the USA, Chicago, IL
President’s Council on Fitness, Sports, & Nutrition, Rockville, MD
The JPB Foundation, New York, NY
Robert Wood Johnson Foundation, Princeton, NJ
Nicolas P. Pronk
HealthPartners, Inc., Minneapolis, MN
Amelie G. Ramirez
Salud America!, San Antonio, TX
Notah Begay III Foundation, Santa Ana Pueblo, NM
S.R. Strategy, LLC, Washington, DC
Jose (Pepe) M. Saavedra
Nestlé Nutrition, North America, Florham Park, NJ
Chartwells School Dining Services, Toms River, NJ
James F. Sallis
University of California, San Diego
Eduardo J. Sanchez
American Heart Association, Dallas, TX
Joint Center for Political and Economic Studies, Washington, DC
Partnership for a Healthier America, Washington, DC
Loel S. Solomon
Kaiser Permanente, Oakland, CA
Alison L. Steiber
Academy of Nutrition and Dietetics, Chicago, IL
General Mills, Inc., Minneapolis, MN
Reebok, International, Canton, MA
Tish Van Dyke
Edelman, Washington, DC
Alliance for a Healthier Generation, New York, NY
James R. Whitehead
American College of Sports Medicine, Indianapolis, IN
DISCLAIMER: This workshop in brief has been prepared by Steve Olson, rapporteur, as a factual summary of what occurred at the meeting. The statements made are those of the authors or individual meeting participants and do not necessarily represent the views of all meeting participants, the planning committee, or the National Academies.
This workshop in brief was reviewed by Debbie I. Chang, Nemours Foundation; Christina Economos, Tufts University; and Lisa Gable, Healthy Weight Commitment Foundation; and coordinated by Chelsea Frakes, Institute of Medicine, to ensure that it meets institutional standards for quality and objectivity.
This workshop was partially supported by Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy for Pediatrics; American College of Sports Medicine; American Council on Exercise; American Heart Association; American Society for Nutrition; Bipartisan Policy Center; Blue Cross Blue Shield of North Carolina; Child Obesity 180/Tufts University; Edelman; General Mills, Inc.; Greater Rochester Health Foundation; Health Partners; Healthy Weight Commitment Foundation; Highmark, Inc.; JPB Foundation; Kaiser Permanente; Kellogg Company; Kresge Foundation; Mars, Inc.; Nemours Foundation; Nestlé Nutrition, North America; Nestlé USA; The Obesity Society; Partnership for a Healthier America; President’s Council on Fitness, Sports, and Nutrition; Reebok, International; Robert Wood Johnson Foundation; Salud America!; Sesame Workshop; and YMCA.
For additional information regarding the workshop, visit www.iom.edu/currentobesitysolutions.
Copyright 2014 by the National Academy of Sciences. All rights reserved.