Linking Personal Responsibility, Economics, and Policy Change to Lifestyle Behaviors

Linking Personal Responsibility, Economics, and Policy Change to Lifestyle Behaviors

William H. Dietz, MD, PhDDirector of the Division of Nutrition, Physical

Activity, and ObesityCenters for Disease Control and Prevention

1999

Obesity Trends Among U.S. AdultsBRFSS, 1990, 1999, 2009

2009

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years

0

10

20

30

40

50

1999-2000 2001-2002 2003-2004 2005-2006

Perc

en

t

Non-Hispanic White Non-Hispanic Black Mexican American

Ogden CL et al. JAMA 2008;299:2401

Changes in Obesity Prevalence by Race/ethnicity, Girls 2-19 Years

0

10

20

30

40

50

1999-2000 2001-2002 2003-2004 2005-2006

Perc

en

t

Non-Hispanic White Non-Hispanic Black Mexican American

Ogden CL et al. JAMA 2008;299:2401

Flegal KM et al. JAMA 2010;303:235

Changes in Prevalence of Obesity in Men 1999-2008

05

10152025303540

1999-2000 2001-2002 2003-2004 2005-2006 2007-2008

WhiteBlackM-A

Prevalence

Year

Flegal KM et al. JAMA 2010;303:235

Changes in Prevalence of Obesity in Women 1999-2008

0

10

20

30

40

50

60

1999-2000

2001-2002

2003-2004

2005-2006

2007-2008

WhiteBlackM-A

Prevalence

Year

Changes in the Prevalence of Adult Obesity: NHANES II – NHANES – 2007-2008

NHANES II -1999-2000 1999-2000 – 2007-2008

Men 0.6 %/y 0.47 %/yWomen 0.7 %/y 0.21 %/y

2003-2004 – 2007-2008 Men 0.18 %/y

Annual Adult per Capita Cigarette Consumption and Major Smoking and Health Events – US 1900-1998

Annual Adult per Capita Cigarette Consumption and Major Smoking and Health Events – US 1900-1998

YearYear

Thousands per yearThousands per year

19001900 19101910 19201920 19301930 19401940 19501950 19601960 19701970 19801980 19901990

Great DepressionGreat Depression

End of WW IIEnd of WW II

1st Surgeon General’s report

1st Surgeon General’s report

Broadcast advertising banBroadcast advertising ban

Federal cigarettetax doubles

Federal cigarettetax doubles

Fairness Doctrinemessages on TV and radio

Fairness Doctrinemessages on TV and radio

Nonsmoker’s rightsmovement begins

Nonsmoker’s rightsmovement begins

1st smoking cancer concern1st smoking

cancer concern Surgeon General’s report onenvironmentalTobacco smoke

Surgeon General’s report onenvironmentalTobacco smoke

Master settlement agreement

Master settlement agreement

Nicotine medications Available over the counter

Nicotine medications Available over the counter

1st World Conferenceon smoking and health1st World Conference

on smoking and health

19981998

1st Great American smokeout1st Great American smokeout

Elements Common to Social Movements

Shared and personalized perception of a threatCommon frameGrass roots commitmentSocial network focused on collective actionLocal nodes with dense social ties, linked to other

groups with weak bridging ties (rapid diffusion of innovation)

Organizational structure

Average Daily Energy Gap (kcal/day) Between 1988-94 and 1999-2002

Excess Weight Gained(Lb)

Daily Energy Gap (kcal/day)

All Teens 10 110 -165

Overweight Teens 58 678 -1,017

Sugar drinks (SDs) = 250 Kcal/dOnly 21-50 Kcal/d of calories from SDs consumed in schools

Healthy Weight Commitment – 1.5 trillion Kcal reduction12.5 Kcal per capita

Quality PE = 35 Kcal/d

Principal Targets for Obesity Prevention and Control

Pregnancy: pre-pregnant weight, weight gain, diabetes, smoking

Reduce energy intakeDecrease high and increase low ED foods Increase fruit and vegetable intakeReduce sugar drinksDecrease television time

BreastfeedingIncrease energy expenditure

Increase daily physical activity

CDC Perspective

Identification of effective interventions more important than identification of cause

Focus on population strategies that change the food and physical activity environments

Interventions aimed at single targets likely less effective than comprehensive multi-sectoral approaches

Rely on evidence-based practice and practice-based evidence

12

Settings for the Prevention and Treatment of Obesity

Settings for the Prevention and Treatment of Obesity

• Industry• Medical settings• Child care• School• Work site• Community• State

• Industry• Medical settings• Child care• School• Work site• Community• State

U.S. State Regulations for Obesity Prevention in Child Care (Benjamin, et al. BMC Public Health 2008; 8:188)

IndicatorChild Care Centers

(# of states) Family Child Care

Homes (# of states)

Water freely available 41 34

Limit SSB 7 7

Limit low nutr. foods 9 7

No forcing to eat 32 32

No food as rewards 10 5

Support BF 9 3

Limit screen time 17 15

Required PA 3 3

NYCDHMH, Amend Article 47, NYC Health Code; Applies to Group Day Care in NYC

Television, video and other visual viewing– Cannot be used for children <2 yo– Limited 60 minutes per day of educational programs or

programs that actively engage child movement for children 2+ yo

60’ physical activity requiredEliminate sugar drinksProvide 1% or no-fat milkMake water freely available

Childhood Obesity Task Force Recommendations1.6: Early childhood settings should support breastfeeding.1.9: The AAP guidelines on screen time should be made more available in

early childhood settings. 1.10: The Federal government……should provide clear, actionable guidance

to states…..on how to increase physical activity, improve nutrition and reduce screen time in early child care settings.

1.11: States should be encouraged to strengthen licensing standards and Quality Rating and Improvement Systems to support good program practices regarding nutrition, physical activity and screen time in child care settings.

1.12: The federal government should look for opportunities in all early childhood programs it funds (CACFP, Head Start, DoD, etc) to base policies and practices on current scientific evidence related to child nutrition and physical activity, and seek to improve access to these programs

National InitiativesNational Initiatives

SG Vision for a Healthy and Fit NationLet’s MoveChild Nutrition Reauthorization – Healthy Hunger-free Kids ActChildhood Obesity Task ForceHHS Healthy Weight Task ForceNational Action Plan for Physical ActivityHealthy People 2020Dietary Guidelines for AmericansCommunities Putting Prevention to Work (CPPW)Surgeon General’s Call to Action on BreastfeedingFTC Guidelines for Foods Marketed to ChildrenAffordable Care Act

Pillars of Let’s MovePillars of Let’s Move

Goal: End childhood obesity in a generationHelping parents make healthy choices

Menu labelingFront of Pack Labeling

Serving healthier foods in schoolsChild Nutrition Reauthorization

Accessing healthy affordable foodHealthy Food Financing Initiative

Increasing physical activity

Let’s Move Initiatives

• Let’s Move Outside (Parks and Recreation)• Let’s Move Cities and Towns (n = 470)• Chefs Move to Schools• Let’s Move Salad Bars to Schools• Let’s Move in Indian Country

– Baby Friendly Hospitals by 2012– Increased access to child nutrition programs– HUSSC in schools

Child Nutrition ReauthorizationChild Nutrition Reauthorization

• Nutrition standards for all foods served in schools• Performance-based reimbursement for compliance with school meal standards• Child care: update CACFP standards, free water available, encourage daily PA and limit media use• Performance bonus for states that increase % breastfed infants• Broadened use of SNAP-Ed funds to address policy and environmental initiatives

Childhood Obesity Task Force Report

Added “Early Childhood”Prenatal careBreastfeeding Screen timeEarly care and educationChemical exposures

70 recommendations across Early Childhood, Empowering parents and caregivers, Healthy food in schools, Access to healthy affordable food, and Increasing physical activity

National InitiativesNational Initiatives

SG Vision for a Healthy and Fit NationLet’s MoveChild Nutrition Reauthorization – Healthy Hunger-free Kids ActChildhood Obesity Task ForceHHS Healthy Weight Task ForceNational Action Plan for Physical ActivityHealthy People 2020Dietary Guidelines for AmericansCommunities Putting Prevention to Work (CPPW)Surgeon General’s Call to Action on BreastfeedingFTC Guidelines for Foods Marketed to ChildrenAffordable Care Act

American Recovery and Reinvestment Act

$373m for Communities Putting Prevention to Work (CPPW)Miami-Dade County: procurement policies in schools,

hospitals, and community institutionsSan Antonio: complete streets, schools open after hours

for physical activity $120m for States, Territories and Tribes for CPPW-STI

Rhode Island: integrate active living into planningMinnesota: increase schools meeting IOM

recommendations; procurement policies to reduce sodium and eliminate trans fat

Nutrition Strategies Across All States and Territories

Physical Activity Strategies Across All States and Territories

Affordable Care Act. Title IV: Prevention of Chronic Disease and Improving Public Health

Subtitle A – Modernizing disease prevention and PH systems• Sec 4001: National Prevention, Health Promotion and Public Health Council• Sec 4002: Prevention and public health fund• Sec 4003: Clinical and community preventive services

Subtitle C – Creating healthier communities• Sec 4201: Community Transformation Grants• Sec 4205: Menu labeling• Sec 4207: Reasonable break time for nursing mothers

Affordable Care Act. Title IV: Prevention of Chronic Disease and Improving Public Health

Subtitle D – Support for Prevention and Public Health Innovation• Sec 4303: CDC and employer-based wellness programs• Sec 4306: Childhood obesity demonstration project

Elements Common to Social Movements

Shared and personalized perception of a threatCommon frameGrass roots commitmentSocial network focused on collective actionLocal nodes with dense social ties, linked to other

groups with weak bridging ties (rapid diffusion of innovation)

Organizational structure