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Preventing Childhood Obesity provides a broad-based examination of the nature, extent, and consequences of obesity in U.S. children and youth, including the social, environmental, medical, and dietary factors responsible for its increased prevalence. The book also offers a prevention-oriented action plan that identifies the most promising array of short-term and longer-term interventions, as well as recommendations for the roles and responsibilities of numerous stakeholders in various sectors of society to reduce its future occurrence. Preventing Childhood Obesity explores the underlying causes of this serious health problem and the actions needed to initiate, support, and sustain the societal and lifestyle changes that can reverse the trend among our children and youth.
Health in the Balance
Copyright © 2005 National Academy of Sciences
All right reserved.
Despite steady progress over most of the past century toward ensuring the health of our country's children, we begin the 21st century with a startling setback-an epidemic of childhood obesity. This epidemic is occurring in boys and girls in all 50 states, in younger children as well as adolescents, across all socioeconomic strata, and among all ethnic groups-though specific subgroups, including African Americans, Hispanics, and American Indians, are disproportionately affected. At a time when we have learned that excess weight has significant and troublesome health consequences, we nevertheless see our population, in general, and our children, in particular, gaining weight to a dangerous degree and at an alarming rate.
The increasing prevalence of childhood obesity throughout the United States has led policy makers to rank it as a critical public health threat. Over the past three decades, its rate has more than doubled for preschool children aged 2 to 5 years and adolescents aged 12 to 19 years, and it has more than tripled for children aged 6 to 11 years. At present, approximately nine million children over 6 years of age are considered obese. These trends mirror a similar profound increase over thesame approximate period in U.S. adults as well as a concurrent rise internationally, in developed and developing countries alike.
Childhood obesity involves immediate and long-term risks to physical health. For children born in the United States in 2000, the lifetime risk of being diagnosed with diabetes at some point in their lives is estimated at 30 percent for boys and 40 percent for girls if obesity rates level off. Young people are also at risk of developing serious psychosocial burdens related to being obese in a society that stigmatizes this condition.
There are also considerable economic costs. The national health care expenditures related to obesity and overweight in adults alone have been estimated to range from approximately $98 billion to $129 billion after adjusting for inflation and converting estimates to 2004 dollars. Understanding the causes of childhood obesity, determining what to do about them, and taking appropriate action require attention to what influences eating behaviors and physical activity levels because obesity prevention involves a focus on energy balance (calories consumed versus calories expended). Although seemingly straightforward, these behaviors result from complex interactions across a number of relevant social, environmental, and policy contexts.
U.S. children live in a society that has changed dramatically in the three decades over which the obesity epidemic has developed. Many of these changes-such as both parents working outside the home, longer work hours by both parents, changes in the school food environment, and more meals eaten outside the home, together with changes in the physical design of communities often affect what children eat, where they eat, how much they eat, and the amount of energy they expend in school and leisure time activities. Other changes, such as the growing diversity of the population, influence cultural views and marketing patterns. Use of computers and video games, along with television viewing, often occupy a large percentage of children's leisure time and potentially influence levels of physical activity for children as well as for adults. Many of the social and cultural characteristics that the U.S. population has accepted as a normal way of life may collectively contribute to the growing levels of childhood obesity. An understanding of these contexts, particularly regarding their potential to be modified and how they may facilitate or impede development of a comprehensive obesity prevention strategy, is essential for reducing childhood obesity.
DEVELOPING AN ACTION PLAN FOR OBESITY PREVENTION
The Institute of Medicine Committee on Prevention of Obesity in Children and Youth was charged with developing a prevention-focused action plan to decrease the prevalence of obesity in children and youth in the United States. The primary emphasis of the committee's task was on examining the behavioral and cultural factors, social constructs, and other broad environmental factors involved in childhood obesity and identifying promising approaches for prevention efforts. The plan consists of explicit goals for preventing obesity in children and youth and a set of recommendations, all geared toward achieving those goals, for different segments of society (Box ES-1).
Obesity prevention requires an evidence-based public health approach to assure that recommended strategies and actions will have their intended effects. Such evidence is traditionally drawn from experimental (randomized) trials and high-quality observational studies. However, there is limited experimental evidence in this area, and for many environmental, policy, and societal variables, carefully designed evaluations of ongoing programs and policies are likely to answer many key questions. For this reason, the committee chose a process that incorporated all forms of available evidence-across different categories of information and types of study design-to enhance the biological, psychosocial, and environmental plausibility of its inferences and to ensure consistency and congruency of information.
Because the obesity epidemic is a serious public health problem calling for immediate reductions in obesity prevalence and in its health and social consequences, the committee believed strongly that actions should be based on the best available evidence-as opposed to waiting for the best possible evidence. However, there is an obligation to accumulate appropriate evidence not only to justify a course of action but to assess whether it has made a difference. Therefore, evaluation should be a critical component of any implemented intervention or change.
Childhood obesity prevention involves maintaining energy balance at a healthy weight while protecting overall health, growth and development, and nutritional status. The balance is between the energy an individual consumes as food and beverages and the energy expended to support normal growth and development, metabolism, thermogenesis, and physical activity. Although "energy intake = energy expenditure" looks like a fairly basic equation, in reality it is extraordinarily complex when considering the multitude of genetic, biological, psychological, sociocultural, and environmental factors that affect both sides of the equation and the interrelationships between these factors. For example, children are strongly influenced by the food- and physical activity-related decisions made by their families, schools, and communities. Furthermore, it is important to consider the kinds of foods and beverages that children are consuming over time, given that specific types and quantities of nutrients are required to support optimal growth and development.
Thus, changes at many levels and in numerous environments will require the involvement of multiple stakeholders from diverse segments of society. In the home environment, for example, incremental changes such as improving the nutritional quality of family dinners or increasing the time and frequency that children spend outside playing can make a difference. Changes that lead to healthy communities, such as organizational and policy changes in local schools, school districts, neighborhoods, and cities, are equally important. At the state and national levels, large-scale modifications are needed in the ways in which society promotes healthful eating habits and physically active lifestyles. Accomplishing these changes will be difficult, but there is precedent for success in other public health endeavors of comparable or greater complexity and scope. This must be a national effort, with special attention to communities that experience health disparities and that have social and physical environments unsupportive of healthful nutrition and physical activity.
A NATIONAL PUBLIC HEALTH PRIORITY
Just as broad-based approaches have been used to address other public health concerns-including automobile safety and tobacco use-obesity prevention should be public health in action at its broadest and most inclusive level. Prevention of obesity in children and youth should be a national public health priority.
Across the country, obesity prevention efforts have already begun, and although the ultimate solutions are still far off, there is great potential at present for pursuing innovative approaches and creating linkages that permit the cross-fertilization of ideas. Current efforts range from new school board policies and state legislation regarding school physical education requirements and nutrition standards for beverages and foods sold in schools to community initiatives to expand bike paths and improve recreational facilities. Parallel and synergistic efforts to prevent adult obesity, which will contribute to improvements in health for the entire U.S. population, are also beginning. Grassroots efforts made by citizens and organizations will likely drive many of the obesity prevention efforts at the local level and can be instrumental in driving policies and legislation at the state and national levels.
The additional impetus that is needed is the political will to make childhood obesity prevention a national public health priority. Obesity prevention efforts nationwide will require federal, state, and local governments to commit adequate and sustained resources for surveillance, research, public health programs, evaluation, and dissemination. The federal government has had a longstanding commitment to programs that address nutritional deficiencies (beginning in the 1930s) and encourage physical fitness, but only recently has obesity been targeted. The federal government should demonstrate effective leadership by making a sustained commitment to support policies and programs that are commensurate to the scale of the problem. Furthermore, leadership in this endeavor will require coordination of federal efforts with state and community efforts, complemented by engagement of the private sector in developing constructive, socially responsible, and potentially profitable approaches to the promotion of a healthy weight.
State and local governments have especially important roles to play in obesity prevention, as they can focus on the specific needs of their state, cities, and neighborhoods. Many of the issues involved in preventing childhood obesity-including actions on street and neighborhood design, plans for parks and community recreational facilities, and locations of new schools and retail food facilities-require decisions by county, city, or town officials.
Rigorous evaluation of obesity prevention interventions is essential. Only through careful evaluation can prevention interventions be refined; those that are unsuccessful can be discontinued or refocused, and those that are successful can be identified, replicated, and disseminated.
Recommendation 1: National Priority
Government at all levels should provide coordinated leadership for the prevention of obesity in children and youth. The President should request that the Secretary of the Department of Health and Human Services (DHHS) convene a high-level task force to ensure coordinated budgets, policies, and program requirements and to establish effective interdepartmental collaboration and priorities for action. An increased level and sustained commitment of federal and state funds and resources are needed.
To implement this recommendation, the federal government should:
Strengthen research and program efforts addressing obesity prevention, with a focus on experimental behavioral research and community-based intervention research and on the rigorous evaluation of the effectiveness, cost-effectiveness, sustainability, and scaling up of effective prevention interventions Support extensive program and research efforts to prevent childhood obesity in high-risk populations with health disparities, with a focus both on behavioral and environmental approaches Support nutrition and physical activity grant programs, particularly in states with the highest prevalence of childhood obesity Strengthen support for relevant surveillance and monitoring efforts, particularly the National Health and Nutrition Examination Survey (NHANES) Undertake an independent assessment of federal nutrition assistance programs and agricultural policies to ensure that they promote healthful dietary intake and physical activity levels for all children and youth Develop and evaluate pilot projects within the nutrition assistance programs that would promote healthful dietary intake and physical activity and scale up those found to be successful
To implement this recommendation, state and local governments should:
Provide coordinated leadership and support for childhood obesity prevention efforts, particularly those focused on high-risk populations, by increasing resources and strengthening policies that promote opportunities for physical activity and healthful eating in communities, neighborhoods, and schools Support public health agencies and community coalitions in their collaborative efforts to promote and evaluate obesity prevention interventions
HEALTHY MARKETPLACE AND MEDIA ENVIRONMENTS
Children, youth, and their families are surrounded by a commercial environment that strongly influences their purchasing and consumption behaviors. Consumers may initially be unsure about what to eat for good health. They often make immediate trade-offs in taste, cost, and convenience for longer term health. The food, beverage, restaurant, entertainment, leisure, and recreation industries share in the responsibilities for childhood obesity prevention and can be instrumental in supporting this goal. Federal agencies can strengthen industry efforts through general support, technical assistance, research expertise, and regulatory guidance.
Some leaders in the food industry are already making changes to expand healthier options for young consumers, offer products with reduced energy content, and reduce portion sizes. These changes must be adopted on a much larger scale, however, and marketed in ways that make acceptance by consumers (who may now have acquired entrenched preferences for many less healthful products) more likely. Coordinated efforts among the private sector, government, and other groups are also needed to create, support, and sustain consumer demand for healthful food and beverage products, appropriately portioned restaurant and take-out meals, and accurate and consistent nutritional information through food labels, health claims, and other educational sources. Similarly, the leisure, entertainment, and recreation industries have opportunities to innovate in favor of stimulating physical activity-as opposed to sedentary or passive-leisure pursuits-and portraying active living as a desirable social norm for adults and children.
Children's health-related behaviors are influenced by exposure to media messages involving foods, beverages, and physical activity. Research has shown that television advertising can especially affect children's food knowledge, choices, and consumption of particular food products, as well as their food-purchase decisions made directly and indirectly (through parents). Because young children under 8 years of age are often unable to distinguish between information and the persuasive intent of advertising, the committee recommends the development of guidelines for advertising and marketing of foods, beverages, and sedentary entertainment to children.
Excerpted from Preventing Childhood Obesity Copyright © 2005 by National Academy of Sciences. Excerpted by permission.
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|2||Extent and consequences of childhood obesity||54|
|3||Developing an action plan||79|
|4||A national public health priority||125|
|5||Industry, advertising, media, and public education||153|
|9||Confronting the childhood obesity epidemic||319|
|App||Lessons learned from public health efforts and their relevance to preventing childhood obesity||343|