F as in Fat: Issue Report 2012 How Obesity Threatens America’s Future September 2012 Preventing Epidemics. Protecting People. ACKNOWLEDGEMENTS Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest phi- lanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organiza- tions and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For 40 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org. Follow the Foundation on Twitter www.rwjf.org/twitter or Facebook www.rwjf.org/facebook. This report was supported by the Robert Wood Johnson Foundation. TFAH BOARD OF DIRECTORS Gail Christopher, DN Robert T. Harris, MD John Gates, JD President of the Board, TFAH Treasurer of the Board, TFAH Founder, Operator and Manager Vice President—Program Strategy Former Chief Medical Officer and Senior Nashoba Brook Bakery WK Kellogg Foundation Vice President for Healthcare Alonzo Plough, MA, MPH, PhD BlueCross BlueShield of North Carolina Cynthia M. Harris, PhD, DABT Director, Emergency Preparedness and Response Vice President of the Board, TFAH David Fleming, MD Program Director and Professor Director of Public Health Los Angeles County Department of Institute of Public Health, Florida Seattle King County, Washington Public Health A&M University Arthur Garson, Jr., MD, MPH Eduardo Sanchez, MD, MPH Theodore Spencer Director, Center for Health Policy, University Chief Medical Officer Secretary of the Board, TFAH Professor, Blue Cross Blue Shield of Texas Senior Advocate, Climate Center And Professor of Public Health Services Jane Silver, MPH Natural Resources Defense Council University of Virginia President Irene Diamond Fund REPORT AUTHORS CONTRIBUTORS Elizabeth Goodman, MS Senior Associate Jeffrey Levi, PhD. Kathryn Thomas, MJ Burness Communications Executive Director Senior Communications Officer Trust for America’s Health and Robert Wood Johnson Foundation Adam Zimmerman Associate Professor in the Department of Health Associate Laura C. Leviton, PhD. Burness Communications Policy Special Advisor for Evaluation The George Washington University Robert Wood Johnson Foundation School of Public Health and Health Services PEER REVIEWERS Tina J. Kauh, MS, PhD. Laura M. Segal, MA Research and Evaluation Program Officer Scott Kahn, MD, MPH Director of Public Affairs Robert Wood Johnson Foundation Co-Director Trust for America’s Health George Washington University Weight Chuck Alexander, MA Rebecca St. Laurent, JD Management Center; Senior Vice President, and Director, Public Health Policy Research Manager and Faculty Health Team Trust for America’s Health Department of Health Policy of the Burness Communications George Washington University School of Albert Lang Elizabeth Wenk, MA Public Health and Health Services Communications Manager Vice President Trust for America’s Health Monica Vinluan, JD Burness Communications Project Director, Healthier Communities Initiatives Jack Rayburn The Y Government Relations Representative Trust for America’s Health Introduction The following is a letter from Risa Lavizzo-Mourey, MD, MBA, president and CEO of the Robert Wood Johnson Foundation, and Jeff Levi, PhD, executive director of Trust for America’s Health. T he future health of the United States is at a crossroads, due in large part to the obesity epidemic. Each year, the Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) issue F as in Fat: How Obesity Threatens America’s Future to examine strategies for addressing the obesity crisis. In this ninth edition of the report, TFAH and RWJF also commissioned a new study to look at how obesity could impact the future health and wealth of our nation. This new analysis provides a picture of two pos- all rates of overweight and obesity among fifth-, sible futures for the health of Americans over seventh- and ninth-graders decreased by 1.1 per- the next 20 years: cent from 2005 to 2010, and, in New York City, obesity in grades K-8 decreased 5.5 percent from n f obesity rates continue on their current tra- I 2006-07 to 2010-11.2, 3 In Mississippi, combined jectory, it’s estimated that: rates of overweight and obesity among all pub- s besity rates for adults could reach or ex- O lic elementary school students dropped from 43 ceed 44 percent in every state and exceed percent in 2005 to 37.3 percent in 2011.4 60 percent in 13 states; While these cases showed that pockets of prog- s he number of new cases of type 2 diabe- T ress are possible, they also showed that chil- tes, coronary heart disease and stroke, hy- dren who face the biggest obstacles to healthy pertension and arthritis could increase 10 choices and are at greatest risk for obesity, such times between 2010 and 2020 — and then as children in lower-income families and Black double again by 2030; and and Hispanic children, did not share equally in progress. That’s why a study released just this s besity-related health care costs could in- O month tells the best story of all. crease by more than 10 percent in 43 states and by more than 20 percent in nine states. New data from Philadelphia show the city re- duced obesity rates in ways that also helped to n ut, if we could lower obesity trends by reduc- B close the disparities gap. In addition to achiev- ing the average adult BMI (body mass index) ing an overall decline in obesity rates among by only 5 percent in each state, we could public school students (from 21.5 percent of all spare millions of Americans from serious public school students in the 2006-2007 school health problems and save billions of dollars year to 20.5 percent in the 2009-2010 school in health spending — between 6.5 percent year), the city made the largest improvements and 7.8 percent in costs in almost every state.1 among Black male and Hispanic female stu- As this year’s report details, we have seen impor- dents. For Black male students, rates declined tant inroads made toward preventing and reduc- from 20.66 percent to 19.08 percent, and rates ing obesity around the country, especially among for Hispanic female students declined from children. We know that real changes are possible. 22.26 percent to 20.61 percent within the same But we also have found that efforts will need to timeframe. We need to learn from the City of be intensified if we are going to achieve a major Brotherly Love and spread the actions and poli- reduction in obesity and related health problems. cies that work so all children can enjoy the ben- efits of better health. The promising results we see in some cities and states pave the way for more intensive efforts. These pockets of progress around the country Multiple studies and reports have demonstrated are showing the positive impact that many poli- that the cities and states that took an early and cies and programs are having — but they need comprehensive approach to preventing obesity to be taken to scale. Fortunately, we know a lot have demonstrated progress toward reversing about what it will take to bend the obesity curve the epidemic. For instance, in California, over- in America. 3 n tepping up the investment in evidence-based, S ing overweight or obese in the first place. locally implemented prevention programs The research shows that a strategy of primary could help achieve results. The U.S. Centers prevention that focuses on avoiding further for Disease Control and Prevention (CDC), gain can help improve health and reduce The New York Academy of Medicine (NYAM) costs, and is a realistic and achievable goal. and others have identified a range of programs For example, in 2010, researchers reviewed that have proved effective in reducing obesity 36 studies of corporate wellness programs, and obesity-related disease levels by 5 percent including those with successful weight-loss el- or — in some cases — more. For example, ements, and calculated that employers saved a study of the Diabetes Prevention Program an average of $6 for every $1 spent. Research- found that randomly selected participants ers also noted that other benefits of such pro- reduced their diabetes risk by 16 percent for grams likely would include improved health.6 every kilogram (a little more than 2 pounds, F as in Fat is an annual reminder of how critical 3 ounces) of weight they lost over a follow-up it is to provide everyone living in our country, period of approximately three years. Another particularly our nation’s children, with the op- study reported the effects of an educational portunity to be as healthy as they can be. The and mass media campaign developed by the forecasting study in this year’s report demon- Heart Health Program in Pawtucket, R.I. strates what’s at stake. Five years into the intervention, the risks for cardiovascular disease and coronary heart If we take action, the number of Americans, par- disease also had decreased by 16 percent for ticularly children, we could spare from type 2 randomly selected participants.5 diabetes, heart disease, cancer and other health problems is striking, and the savings in health n ecalibrating our goals could help us dra- R care costs and increased productivity would matically slow the national growth in obesity have a real and positive impact on the economy. rates by preventing adults from gaining addi- Investing in prevention today means a health- tional weight (including individuals who are ier, more productive and brighter future for our currently obese, overweight and at a healthy country and our children. weight), and by preventing kids from becom- Background on Obesity and Body Mass Index (BMI) Currently, more than 35 percent of adults are The study also forecasts what would happen obese.7 Obesity is defined as an excessively high if average BMI in the state was reduced by 5 amount of body fat or adipose tissue in relation percent, which could translate to a 9 percent to to lean tissue. An adult is considered obese if his 14 percent reduction in the states’ obesity rates or her body mass index (BMI) is 30 or higher. by 2030 depending on the state. The new modeling study in this year’s For example, on an individual level, reducing the report projects what obesity rates and the BMI of an average adult by 1 percent would be consequences for disease rates and health equivalent to a weight loss of approximately 2.2 care costs could be if the average state BMI pounds.8 According to the CDC, the average continued to grow based on current trends for American male over age 20 weighs 194.7 each state’s population over the next 20 years. pounds and the average American woman over age 20 weighs 164.7 pounds.9 4 Childhood Obesity: What’s At Stake Childhood obesity rates have climbed dramati- chosen less as friends and are generally not as cally in the past 30 years. In 1980, the obesity well-liked as healthy-weight children. Studies also rate for children ages 6 to 11 was 6.5 percent. have found that weight-based teasing is related to By 2008, the rate grew to 19.6 percent. And, increased susceptibility to depression.18, 19, 20 in 1980, 5 percent of teens ages 12 to 19 were Reducing and preventing childhood obesity is obese. That rate climbed to 17 percent (approxi- critical to improving the future health of the mately 12.5 million children and teens) by 2010.10 country, and consequently would help to lower This change is having a major impact on the health care costs and improve productivity. health of children and youths. If we don’t reverse What’s more, research supports the concept the epidemic, the current generation of young that focusing on children and getting them on people could be the first in U.S. history to live a healthy path early in life is one of the areas sicker and die younger than their parents’ genera- where the greatest successes can be achieved. tion. Nearly one-third of children and teens are For instance, a recent study from the American currently obese or overweight, which is putting Journal of Preventive Medicine found that eliminat- them at higher risks for developing a range of dis- ing just 41 calories a day per person could halt ris- eases and developing them earlier in life.11 ing body weight trends in children and teens ages Children who are obese are more than twice 2 to 19, and eliminating 161 calories per day per as likely to die before the age of 55 as children person could reduce childhood obesity to 5 per- whose BMI is in the healthy range.12 Around cent by 2020.21 Researchers have created a tool 70 percent of obese youths have at least one to help estimate the impact of nutrition or physi- additional risk factor for cardiovascular disease, cal activity interventions on specific populations. such as elevated total cholesterol, triglycerides, The tool is available at http://caloriccalculator.org. insulin or blood pressure.13 Overweight and Programs around the country are helping to change obese children and teens also are at higher risk our culture to encourage healthier nutrition and in- for other health conditions, including asthma creased physical activity. Some areas where there and sleep-disordered breathing.14, 15 Children have been concerted efforts to prevent and reduce who are obese after the age of 6 are 50 percent childhood obesity are demonstrating promising more likely to be obese as adults, and among results. Initiatives ranging from Let’s Move to the overweight tweens and teens ages 10 to 15, 80 Alliance for a Healthier Generation to the Y are all percent were obese at age 25.16, 17 having an impact and leading to positive change. Being obese or overweight also can have a major Reversing the childhood obesity crisis is at the social and emotional impact on children and core of the future health and wealth of the youths. For instance, studies have found that country. The evidence shows that the goal is overweight and obese children and teens face a achievable, but only if there is a sufficient invest- higher risk for more severe and frequent bully- ment in effective programs and policies. ing, are rejected by their peers more often, are 5 F as in Fat 2012 — CONTENTS Section 1:Obesity Rates and Trends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A. Adult obesity and overweight rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 B. Childhood and youth obesity and overweight rates . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Section 2:Two Futures for America’s Health. . . . . . . . . . . . . . . . . . . . . . . . . 23 A. Key Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 B. Five Top Obesity-Related Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1. Type 2 Diabetes and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 2. Coronary Heart Disease and Stroke and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 3. Hypertension and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 4. Arthritis and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 5. Obesity-Related Cancer and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 C. Some Additional Health and Obesity Issues. . . . . . . . . . . . . . . . . . . . . . . . . . 45 1. Maternal Health and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 2. Breastfeeding and Obesity Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3. Mental Health, Neurological Conditions and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . 48 4. Kidney Disease and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 5. Liver Disease and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 6. HIV/AIDS and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Section 3:Strategies and Policy Approaches to Reducing Obesity, Improving Nutrition and Increasing Activity. . . . . . . . . . . . . . . . . 51 A. State Responsibilities and Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 1. Obesity-Related Legislation for Healthy Schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 2. Obesity-Related Legislation for Healthy Communities. . . . . . . . . . . . . . . . . . . . . . . . 63 B. Federal Policies and Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 C. Examples of Prevention in Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 1. Small Businesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 2. Faith-Based Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 3. Schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Section 4:Conclusions and Recommendations. . . . . . . . . . . . . . . . . . . . . . . . 95 Appendix A:Physical Activity and Nutrition Trends. . . . . . . . . . . . . . . . . . . . 102 Appendix B:Methodologies for Rates and Trends. . . . . . . . . . . . . . . . . . . . . . 109 Appendix C:Methodologies for 2020 and 2030 Modeling Projections. . . . . . . 111 7 F as in Fat 2012 Major Findings In August 2012, the Centers for Disease Control and Prevention released the latest rates of adult obesity in the United States. In 2011: n Twelve states had an adult obesity rate above 30 percent. n Mississippi had the highest rate of obesity at 34.9 percent, while Colorado had the lowest rate at 20.7 percent.  n Twenty-six of the 30 states with the highest obesity rates are in the Midwest and South. n All 10 of the states with the highest rates of type 2 diabetes and hypertension are in the South. Two Futures for America’s Health: Projections for Obesity, Diseases and Costs The new analysis commissioned by TFAH and RWJF, and conducted by the National Heart Forum (NHF) was based on a peer-reviewed model published in The Lancet. The analysis includes projections for potential rates of obesity, health problems and health care costs in the year 2030 if current trends continued, and it examined how reducing the average body mass index (BMI) in the state by 5 percent could lower obesity rates and decrease costs. 22 2030: Obesity on Current Track 2030: BMI Reduced by 5 Percent Obesity Rates n More than 60 percent of people could n No state would have an obesity rate be obese in 13 states; above 60 percent; n More than half of people could be n More than half of people would be obese in 39 states; obese in 24 states; n n all 50 states, more than 44 percent I n Two states would have obesity rates of people could be obese. under 40 percent. Obesity-Related By 2030, for every 100,000 people, the Thousands of cases of type 2 diabetes, Disease Rates number of new Americans who could coronary heart disease and stroke, develop the five top diseases associated hypertension and arthritis could be with obesity could range from: avoided in all states; n Between 8,658 in Utah to 15,208 in More than 100 cases of obesity-related West Virginia (average for all states: cancer per 100,000 people could be 12,127) for new cases of type 2 diabetes prevented in all states; n Between 16,730 in Utah to 35,519 in States could avoid — per 100,000 people: West Virginia (average for all states: n Between 1,810 and 3,213 new cases of 26,573) for new cases of coronary type 2 diabetes heart disease and stroke n Between 1,427 and 2,512 new cases of n Between 17,790 in Utah to 30,508 in hypertension Maine (average for all states: 24,923) n Between 1,339 and 2,898 new cases of for new cases of hypertension coronary heart disease and stroke n Between 12,504 in Utah to 18,725 in n Between 849 and 1,382 new cases of Maine (average for all states: 16,152) arthritis for new cases of arthritis n Between 101 and 277 new cases of n Between 2,468 in Utah to 4,897 in cancer. Maine (average for all states: 3,781) for new cases of obesity-related cancer Obesity-Related n Nine states could see increases of n Every state except Florida would Health Care more than 20 percent; save between 6.5 and 7.8 percent on Costs n 16 states and Washington, D.C., could obesity-related health costs compared expect increases between 15-20 percent; with 2030 projected costs if rates continue to increase at their current n 8 states could expect increases 1 pace. (Florida would save 2.1 percent). between 10-15 percent; n Only seven states could have increases lower than 10 percent. 8 Obesity Rates and Related Trends M ore than two-thirds (68 percent) of American adults are either overweight or obese.23 Adult obesity rates have more than doubled — from 15 percent 1 Section in 1980 to 35 percent in 2010, based on a national survey. 24, 25 Rates of obesity among children ages 2–19 have who are either obese or overweight. Research- more than tripled since 1980.26,27 According to ers at the U.S. Centers for Disease Control and the most recent National Health and Nutrition Prevention (CDC) report that, during the pe- Examination Survey (NHANES), 16.9 percent riod between 1999 and 2008, there was no sta- of children ages 2–19 are obese, and 31.7 per- tistically significant change in the number of cent are overweight or obese.28 This translates children and adolescents with high BMI-for-age, to more than 12 million children and adoles- except among the very heaviest boys ages 6–19.29 cents who are obese and more than 23 million A. ADULT OBESITY AND OVERWEIGHT RATES In August 2012, CDC released the latest rates of The U.S. Department of Health and Human obesity in the states. Twelve states currently have Services (HHS) set a national goal to reduce an adult obesity rate over 30 percent. Mississippi adult obesity rates to 30 percent in every state had the highest rate of obesity at 34.9 percent, by the year 2020. Healthy People 2020 also sets while Colorado had the lowest rate at 20.7 per- a goal of increasing the percentage of people at cent. Twenty-six of the 30 states with the highest a healthy weight (BMI <25) from 30.8 percent rates of obesity are in the South and Midwest. to 33.9 percent by 2020. Northeastern and Western states comprise most of the states with the lowest rates of obesity. 2011 Obesity Rates WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA FL AK HI n <25% n >25% & <30% n >30% 9 CHART ON OBESITY AND OVERWEIGHT RATES ADULTS Overweight & Obesity Diabetes Physical Inactivity Hypertension Obese 2011 Percentage 2011 Percentage 2011 Percentage 2011 Percentage 2011 Percentage States Ranking Ranking Ranking Ranking (95% Conf Interval) (95% Conf Interval) (95% Conf Interval) (95% Conf Interval) (95% Conf Interval) Alabama 32.0% (+/- 1.5) 4 66.8% (+/- 1.6) 11.8% (+/- 0.9) 4 32.6% (+/- 1.6) 5 40.0% (+/- 1.6) 1 Alaska 27.4% (+/- 2.2) 28 66.5% (+/- 2.4) 7.9% (+/- 1.4) 46 22.0% (+/- 2.0) 41 29.4% (+/- 2.1) 37 Arizona 24.7% (+/- 2.1) 40 62.5% (+/- 2.4) 9.5% (+/- 1.3) 25 24.2% (+/- 2.2) 34 28.0% (+/- 2.0) 47 Arkansas 30.9% (+/- 2.2) 7 65.0% (+/- 2.3) 11.2% (+/- 1.2) 6 30.9% (+/- 2.1) 7 35.7% (+/- 2.1) 8 California 23.8% (+/- 0.9) 46 60.2% (+/- 1.1) 8.9% (+/- 0.6) 34 19.1% (+/- 0.9) 49 27.8% (+/- 0.9) 48 Colorado 20.7% (+/- 1.1) 51 56.1% (+/- 1.3) 6.7% (+/- 0.6) 50 16.5% (+/- 1.0) 51 24.9% (+/- 1.0) 50 Connecticut 24.5% (+/- 1.5) 42 59.6% (+/- 1.8) 9.3% (+/- 0.9) 31 25.3% (+/- 1.6) 28 29.7% (+/- 1.5) 36 Delaware 28.8% (+/- 1.9) 19 63.9% (+/- 2.2) 9.7% (+/- 1.1) 22 27.0% (+/- 1.9) 13 34.6% (+/- 1.9) 10 D.C. 23.7% (+/- 1.9) 47 52.8% (+/- 2.4) 9.1% (+/- 1.1) 33 19.8% (+/- 1.8) 47 29.9% (+/- 2.0) 33 Florida 26.6% (+/- 1.3) 32 63.4% (+/- 1.4) 10.4% (+/- 0.8) 11 26.9% (+/- 1.3) 16 34.2% (+/- 1.3) 12 Georgia 28.0% (+/- 1.4) 24 62.7% (+/- 1.6) 10.1% (+/- 0.7) 18 26.8% (+/- 1.4) 18 32.3% (+/- 1.3) 18 Hawaii 21.8% (+/- 1.5) 50 55.8% (+/- 1.8) 8.4% (+/- 0.8) 38 21.3% (+/- 1.5) 45 28.7% (+/- 1.5) 43 Idaho 27.0% (+/- 1.8) 30 62.3% (+/- 2.1) 9.4% (+/- 1.0) 29 21.4% (+/- 1.7) 44 29.4% (+/- 1.7) 37 Illinois 27.1% (+/- 1.8) 29 64.1% (+/- 2.0) 9.7% (+/- 1.1) 22 25.2% (+/- 1.7) 31 31.0% (+/- 1.8) 24 Indiana 30.8% (+/- 1.4) 8 65.7% (+/- 1.5) 10.2% (+/- 0.8) 15 29.3% (+/- 1.4) 9 32.7% (+/- 1.3) 15 Iowa 29.0% (+/- 1.4) 18 64.8% (+/- 1.5) 8.2% (+/- 0.7) 43 25.9% (+/- 1.3) 27 29.9% (+/- 1.3) 33 Kansas 29.6% (+/- 0.9) 13 64.4% (+/- 0.9) 9.5% (+/- 0.5) 25 26.8% (+/- 0.8) 18 30.8% (+/- 0.8) 27 Kentucky 30.4% (+/- 1.5) 10 66.6% (+/- 1.6) 10.8% (+/- 0.8) 9 29.4% (+/- 1.5) 8 37.9% (+/- 1.5) 5 Louisiana 33.4% (+/- 1.5) 2 67.6% (+/- 1.5) 11.8% (+/- 0.9) 4 33.8% (+/- 1.5) 4 38.3% (+/- 1.4) 4 Maine 27.8% (+/- 1.1) 25 65.0% (+/- 1.2) 9.6% (+/- 0.6) 24 23.0% (+/- 1.0) 38 32.2% (+/- 1.0) 19 Maryland 28.3% (+/- 1.4) 22 64.4% (+/- 1.6) 9.4% (+/- 0.8) 29 26.1% (+/- 1.4) 26 31.3% (+/- 1.4) 21 Massachusetts 22.7% (+/- 1.0) 49 59.4% (+/- 1.2) 8.0% (+/- 0.5) 45 23.5% (+/- 1.0) 37 29.2% (+/- 1.0) 40 Michigan 31.3% (+/- 1.3) 5 65.5% (+/- 1.4) 10.0% (+/- 0.8) 19 23.6% (+/- 1.2) 36 34.2% (+/- 1.3) 12 Minnesota 25.7% (+/- 1.1) 36 62.5% (+/- 1.2) 7.3% (+/- 0.6) 49 21.8% (+/- 1.0) 43 26.3% (+/- 1.0) 49 Mississippi 34.9% (+/- 1.4) 1 68.9% (+/- 1.5) 12.3% (+/- 0.8) 1 36.0% (+/- 1.5) 1 39.2% (+/- 1.4) 2 Missouri 30.3% (+/- 1.7) 12 64.8% (+/- 1.8) 10.2% (+/- 1.0) 15 28.5% (+/- 1.6) 10 34.3% (+/- 1.6) 11 Montana 24.6% (+/- 1.4) 41 60.3% (+/- 1.5) 7.9% (+/- 0.7) 46 24.4% (+/- 1.3) 33 30.1% (+/- 1.3) 31 Nebraska 28.4% (+/- 0.8) 21 64.9% (+/- 0.9) 8.4% (+/- 0.5) 38 26.3% (+/- 0.8) 22 28.5% (+/- 0.8) 45 Nevada 24.5% (+/- 2.1) 42 60.3% (+/- 2.4) 10.4% (+/- 1.6) 11 24.1% (+/- 2.2) 35 30.9% (+/- 2.2) 25 New Hampshire 26.2% (+/- 1.5) 35 61.6% (+/- 1.8) 8.7% (+/- 0.8) 37 22.5% (+/- 1.5) 40 30.6% (+/- 1.5) 28 New Jersey 23.7% (+/- 1.1) 47 61.5% (+/- 1.3) 8.8% (+/- 0.6) 36 26.4% (+/- 1.1) 21 30.6% (+/- 1.1) 28 New Mexico 26.3% (+/- 1.3) 34 62.3% (+/- 1.4) 10.0% (+/- 0.8) 19 25.3% (+/- 1.3) 28 28.5% (+/- 1.2) 45 New York 24.5% (+/- 1.4) 42 60.5% (+/- 1.6) 10.4% (+/- 0.9) 11 26.2% (+/- 1.4) 24 30.6% (+/- 1.4) 28 North Carolina 29.1% (+/- 1.5) 17 65.2% (+/- 1.5) 10.8% (+/- 0.8) 9 26.7% (+/- 1.4) 20 32.4% (+/- 1.3) 17 North Dakota 27.8% (+/- 1.6) 25 63.8% (+/- 1.9) 8.3% (+/- 0.8) 42 27.0% (+/- 1.6) 13 28.9% (+/- 1.5) 41 Ohio 29.6% (+/- 1.4) 13 65.8% (+/- 1.4) 10.0% (+/- 0.8) 19 27.0% (+/- 1.3) 13 32.7% (+/- 1.3) 15 Oklahoma 31.1% (+/- 1.4) 6 65.4% (+/- 1.5) 11.1% (+/- 0.8) 8 31.2% (+/- 1.4) 6 35.5% (+/- 1.4) 9 Oregon 26.7% (+/- 1.6) 31 61.6% (+/- 1.7) 9.3% (+/- 0.9) 31 19.7% (+/- 1.5) 48 29.8% (+/- 1.5) 35 Pennsylvania 28.6% (+/- 1.3) 20 64.5% (+/- 1.4) 9.5% (+/- 0.7) 25 26.3% (+/- 1.2) 22 31.4% (+/- 1.2) 20 Rhode Island 25.4% (+/- 1.6) 37 62.5% (+/- 1.8) 8.4% (+/- 0.8) 38 26.2% (+/- 1.5) 24 33.0% (+/- 1.5) 14 South Carolina 30.8% (+/- 1.3) 8 65.9% (+/- 1.4) 12.0% (+/- 0.8) 3 27.2% (+/- 1.3) 11 36.4% (+/- 1.3) 7 South Dakota 28.1% (+/- 1.9) 23 64.5% (+/- 2.2) 9.5% (+/- 1.1) 25 26.9% (+/- 2.0) 16 30.9% (+/- 1.9) 25 Tennessee 29.2% (+/- 2.5) 15 66.5% (+/- 2.8) 11.2% (+/- 1.5) 6 35.2% (+/- 2.7) 2 38.6% (+/- 2.6) 3 Texas 30.4% (+/- 1.4) 10 65.9% (+/- 1.5) 10.2% (+/- 0.8) 15 27.2% (+/- 1.3) 11 31.3% (+/- 1.3) 21 Utah 24.4% (+/- 1.1) 45 58.9% (+/- 1.3) 6.7% (+/- 0.5) 50 18.9% (+/- 1.0) 50 22.9% (+/- 0.9) 51 Vermont 25.4% (+/- 1.4) 37 59.8% (+/- 1.6) 7.7% (+/- 0.7) 48 21.0% (+/- 1.3) 46 29.3% (+/- 1.4) 39 Virginia 29.2% (+/- 1.7) 15 63.4% (+/- 1.9) 10.4% (+/- 1.1) 11 25.0% (+/- 1.0) 32 31.2% (+/- 1.6) 23 Washington 26.5% (+/- 1.2) 33 61.0% (+/- 1.4) 8.9% (+/- 0.7) 34 21.9% (+/- 1.2) 42 30.1% (+/- 1.2) 31 West Virginia 32.4% (+/- 1.6) 3 69.0% (+/- 1.7) 12.1% (+/- 1.0) 2 35.1% (+/- 1.6) 3 37.1% (+/- 1.6) 6 Wisconsin 27.7% (+/- 2.0) 27 64.1% (+/- 2.2) 8.4% (+/- 1.0) 38 22.6% (+/- 1.8) 39 28.9% (+/- 1.8) 41 Wyoming 25.0% (+/- 1.6) 39 61.2% (+/- 1.8) 8.2% (+/- 1.0) 43 25.3% (+/- 1.6) 28 28.7% (+/- 1.6) 43 Source: Behavior Risk Factor Surveillance System (BRFSS), CDC. 10 AND RELATED HEALTH INDICATORS IN THE STATES CHILDREN AND ADOLESCENTS 2011 YRBS 2010 PedNSS 2007 National Survey of Children’s Health Percentage of Percentage of Percentage of High School Percentage of Percentage of Percentage Participating in Obese High School Overweight High Students Who Were Overweight and States Obese Low-Income Ranking Vigorous Physical Activity Students (95% School Students Physically Active At Least Obese Children Children Ages 2-5 Every Day Ages 6-17 Conf Interval) (95% Conf Interval) 60 Minutes on All 7 Days Ages 10-17 Alabama 17.0 (+/- 3.9) 15.8 (+/- 3.0) 28.4 (+/- 4.3) 14.1% 36.1% (+/- 4.6) 6 36.5% Alaska 11.5 (+/- 2.0) 14.4 (+/- 2.1) 21.3 (+/- 2.8) N/A 33.9% (+/- 4.4) 12 30.4% Arizona 10.9 (+/- 1.9) 13.9 (+/- 1.8) 25.0 (+/- 2.0) 14.2% 30.6% (+/- 4.9) 26 28.5% Arkansas 15.2 (+/- 2.1) 15.4 (+/- 2.1) 26.7 (+/- 3.3) 14.1% 37.5% (+/- 4.2) 2 30.7% California N/A N/A N/A 17.2% 30.5% (+/- 6.4) 28 30.0% Colorado 7.3 (+/- 2.4) 10.7 (+/- 2.5) 29.2 (+/- 2.8) 9.1% 27.2% (+/- 5.1) 42 27.6% Connecticut 12.5 (+/- 2.7) 14.1 (+/- 1.9) 26.0 (+/- 3.1) 15.8% 25.7% (+/- 3.7) 45 22.1% Delaware 12.2 (+/- 1.5) 16.9 (+/- 2.1) 24.9 (+/- 2.1) N/A 33.2% (+/- 4.1) 16 31.1% D.C. N/A N/A N/A 13.7% 35.4% (+/- 4.8) 9 26.3% Florida 11.5 (+/- 2.3) 13.6 (+/- 1.1) 25.8 (+/- 1.4) 13.4% 33.1% (+/- 6.1) 17 34.1% Georgia 15.0 (+/- 2.3) 15.8 (+/- 2.2) 25.2 (+/- 3.0) 13.5% 37.3% (+/- 5.6) 3 29.4% Hawaii 13.2 (+/- 2.4) 13.4 (+/- 1.6) 21.0 (+/- 2.3) 9.1% 28.5% (+/- 4.1) 37 28.0% Idaho 9.2 (+/- 1.6) 13.4 (+/- 1.8) 25.9 (+/- 3.4) 11.4% 27.5% (+/- 3.9) 41 25.0% Illinois 11.6 (+/- 1.7) 14.5 (+/- 1.7) 23.2 (+/- 2.3) 14.6% 34.9% (+/- 4.1) 10 26.1% Indiana 14.7 (+/- 1.8) 15.5 (+/- 2.1) 24.2 (+/- 2.7) 14.2% 29.9% (+/- 4.3) 31 31.3% Iowa 13.2 (+/- 3.2) 14.5 (+/- 2.0) 29.1 (+/- 3.3) 14.7% 26.5% (+/- 4.3) 44 27.8% Kansas 10.2 (+/- 1.5) 13.9 (+/- 1.8) 30.2 (+/- 2.5) 13.0% 31.1% (+/- 4.2) 22 25.2% Kentucky 16.5 (+/- 2.5) 15.4 (+/- 1.6) 21.9 (+/- 2.5) 15.6% 37.1% (+/- 4.1) 4 25.9% Louisiana 16.1 (+/- 2.6) 19.5 (+/- 4.5) 24.2 (+/- 3.5) 12.5% 35.9% (+/- 4.6) 7 34.0% Maine 11.5 (+/- 1.4) 14.0 (+/- 1.1) 23.7 (+/- 1.7) 14.3% 28.2% (+/- 3.8) 39 32.7% Maryland 12.0 (+/- 1.7) 15.4 (+/- 2.0) 21.4 (+/- 2.8) 15.7% 28.8% (+/- 4.2) 36 30.7% Massachusetts 9.9 (+/- 1.8) 14.6 (+/- 1.4) 22.4 (+/- 2.6) 16.1% 30.0% (+/- 4.6) 30 26.6% Michigan 12.1 (+/- 1.6) 15.3 (+/- 2.4) 27.0 (+/- 2.7) 13.3% 30.6% (+/- 4.3) 26 33.1% Minnesota N/A N/A N/A 12.7% 23.1% (+/- 4.0) 50 34.8% Mississippi 15.8 (+/- 2.2) 16.5 (+/- 2.0) 25.9 (+/- 3.0) 13.7% 44.4% (+/- 4.3) 1 29.0% Missouri N/A N/A N/A 13.6% 31.0% (+/- 4.1) 23 29.6% Montana 8.5 (+/- 1.1) 12.9 (+/- 1.4) 28.7 (+/- 1.9) 12.2% 25.6% (+/- 3.7) 48 31.5% Nebraska 11.6 (+/- 1.2) 13.6 (+/- 1.3) 28.0 (+/- 1.8) 13.8% 31.5% (+/- 4.6) 21 26.2% Nevada N/A N/A N/A 13.6% 34.2% (+/- 5.4) 11 24.4% New Hampshire 12.1 (+/- 1.7) 14.1 (+/- 2.2) N/A 14.2% 29.4% (+/- 3.9) 35 29.0% New Jersey 11.0 (+/- 2.0) 15.2 (+/- 1.9) 28.0 (+/- 2.8) 17.3% 31.0% (+/- 4.5) 23 29.1% New Mexico 12.8 (+/- 2.1) 14.4 (+/- 1.2) 26.3 (+/- 1.6) 11.7% 32.7% (+/- 5.0) 19 27.0% New York 11.0 (+/- 1.3) 14.7 (+/- 1.0) 25.1 (+/- 2.4) 14.5% 32.9% (+/- 4.4) 18 27.6% North Carolina 12.9 (+/- 3.2) 15.9 (+/- 2.0) 26.0 (+/- 2.4) 15.5% 33.5% (+/- 4.5) 14 38.5% North Dakota 11.0 (+/- 1.7) 14.5 (+/- 2.1) 21.8 (+/- 1.9) 14.1% 25.7% (+/- 3.3) 45 27.1% Ohio 14.7 (+/- 3.1) 15.3 (+/- 2.3) 25.4 (+/- 3.5) 12.4% 33.3% (+/- 4.7) 15 32.1% Oklahoma 16.7 (+/- 3.0) 16.3 (+/- 2.8) 33.1 (+/- 4.1) N/A 29.5% (+/- 4.1) 33 29.6% Oregon N/A N/A N/A 15.1% 24.3% (+/- 3.9) 49 27.9% Pennsylvania N/A N/A N/A 12.0% 29.7% (+/- 4.8) 32 35.4% Rhode Island 10.8 (+/- 2.3) 14.9 (+/- 2.1) 26.7 (+/- 4.0) 15.5% 30.1% (+/- 4.2) 29 27.6% South Carolina 13.3 (+/- 3.0) 16.3 (+/- 2.6) 25.8 (+/- 2.9) 12.8% 33.7% (+/- 4.2) 13 31.2% South Dakota 9.8 (+/- 2.0) 14.1 (+/- 1.4) 27.3 (+/- 3.5) 16.1% 28.4% (+/- 3.9) 38 25.3% Tennessee 15.2 (+/- 1.6) 17.3 (+/- 1.9) 30.2 (+/- 2.8) 14.5% 36.5% (+/- 4.3) 5 29.8% Texas 15.6 (+/- 2.0) 16.0 (+/- 1.4) 27.1 (+/- 2.7) 15.3% 32.2% (+/- 5.6) 20 28.9% Utah 8.6 (+/- 1.7) 12.2 (+/- 2.0) 20.8 (+/- 2.6) 8.7% 23.1% (+/- 4.2) 50 17.6% Vermont 9.9 (+/- 2.0) 13.0 (+/- 1.7) 24.4 (+/- 1.6) 12.2% 26.7% (+/- 4.5) 43 36.6% Virginia 11.1 (+/- 2.5) 17.2 (+/- 2.7) 24.1 (+/- 4.0) 15.5% 31.0% (+/- 4.2) 23 26.2% Washington N/A N/A N/A 14.4% 29.5% (+/- 5.0) 33 27.6% West Virginia 14.6 (+/- 2.4) 15.7 (+/- 2.4) 29.0 (+/- 3.2) 13.7% 35.5% (+/- 3.9) 8 33.2% Wisconsin 10.4 (+/- 1.6) 15.0 (+/- 1.5) 27.7 (+/- 3.6) 14.1% 27.9% (+/- 3.8) 40 28.5% Wyoming 11.1 (+/- 1.4) 12.0 (+/- 1.6) 25.8 (+/- 2.1) N/A 25.7% (+/- 4.0) 45 29.8% Source: Youth Risk Behavior Survey (YRBS) 2011, CDC. YRBS data are collected every 2 years. Percent- Source: Pediatric Nutri- Source: National Survey of Children’s Health, 2007. Overweight and Physical Activity ages are as reported on the CDC website and can be found at <http://www.cdc.gov/HealthyYouth/ tion Surveillance 2010 Among Children: A Portrait of States and the Nation 2009, Health Resources and yrbs/index.htm>. Note that previous YRBS reports used the term “overweight” to describe youth Report, Table 6. Available Services Administration, Maternal and Child Health Bureau. * & red indicates a with a BMI at or above the 95th percentile for age and sex and “at risk for overweight” for those with at http://www.cdc.gov/ statistically significant increase (p<0.05) from 2003 to 2007. Over the same time a BMI at or above the 85th percentile, but below the 95th percentile. However, this report uses the pednss/pednss_tables/pdf/ period, AZ and IL had statistically significant increases in obesity rates, while OR saw terms “obese” and “overweight” based on the 2007 recommendations from the Expert Committee on national_table6.pdf a significant decrease. Meanwhile, NM and NV experienced significant increases in the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity convened rates of overweight children between 2003 and 2007, while AZ had a decrease. by the American Medical Association. “Physically active at least 60 minutes on all 7 days” means that the student did any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of least 60 minutes per day on each of the 7 days before the survey. 11 Obesity Rates by Sex and Race — 2011 Adult Obesity Obesity Rates by Sex Obesity Rates by Race/Ethnicity TOTAL MEN WOMEN WHITE BLACK LATINO Alabama 32.0% (+/- 1.5) 32.3% (+/- 2.5) 31.8% (+/- 1.9) 29.8% (+/- 1.8) 40.1% (+/- 3.3) 28.8% (+/- 13.4) Alaska 27.4% (+/- 2.2) 28.0% (+/- 3.3) 26.8% (+/- 3.0) 25.9% (+/- 2.3) NA 32.3% (+/- 13.1) Arizona 24.7% (+/- 2.1) 24.2% (+/- 3.1) 25.1% (+/- 2.9) 20.6% (+/- 2.1) 27.0% (+/- 13.3) 33.6% (+/- 5.7) Arkansas 30.9% (+/- 2.2) 30.7% (+/- 3.4) 31.1% (+/- 2.7) 31.0% (+/- 2.4) 38.5% (+/- 7.2) 18.4% (+/- 8.9) California 23.8% (+/- 0.9) 23.1% (+/- 1.4) 24.5% (+/- 1.2) 22.0% (+/- 1.1) 33.1% (+/- 4.9) 30.3% (+/- 1.9) Colorado 20.7% (+/- 1.1) 21.1% (+/- 1.6) 20.4% (+/- 1.4) 18.9% (+/- 1.1) 34.9% (+/- 8.0) 26.6% (+/- 3.4) Connecticut 24.5% (+/- 1.5) 25.6% (+/- 2.4) 23.7% (+/- 2.0) 23.1% (+/- 1.7) 32.8% (+/- 6.5) 32.6% (+/- 6.0) Delaware 28.8% (+/- 1.9) 29.1% (+/- 2.9) 28.5% (+/- 2.5) 27.3% (+/- 2.1) 38.2% (+/- 5.3) 22.4% (+/- 9.8) D.C. 23.7% (+/- 1.9) 18.5% (+/- 2.8) 28.4% (+/- 2.8) 10.7% (+/- 2.2) 36.7% (+/- 3.4) 13.3% (+/- 6.2) Florida 26.6% (+/- 1.3) 27.8% (+/- 2.0) 25.6% (+/- 1.7) 25.0% (+/- 1.4) 35.6% (+/- 4.5) 27.9% (+/- 3.6) Georgia 28.0% (+/- 1.4) 26.7% (+/- 2.2) 29.3% (+/- 1.8) 25.0% (+/- 1.6) 36.8% (+/- 3.2) 26.4% (+/- 6.6) Hawaii 21.8% (+/- 1.5) 24.4% (+/- 2.3) 19.3% (+/- 1.9) 19.0% (+/- 2.6) NA 26.9% (+/- 6.2) Idaho 27.0% (+/- 1.8) 26.0% (+/- 2.6) 28.0% (+/- 2.4) 25.8% (+/- 1.8) NA 36.1% (+/- 8.7) Illinois 27.1% (+/- 1.8) 27.8% (+/- 2.7) 26.6% (+/- 2.2) 26.0% (+/- 1.8) 39.2% (+/- 6.2) 25.2% (+/- 6.6) Indiana 30.8% (+/- 1.4) 30.9% (+/- 2.2) 30.9% (+/- 1.9) 29.5% (+/- 1.5) 42.3% (+/- 5.9) 35.1% (+/- 9.2) Iowa 29.0% (+/- 1.4) 30.5% (+/- 2.0) 27.5% (+/- 1.8) 29.2% (+/- 1.4) 27.8% (+/- 10.1) 33.2% (+/- 8.5) Kansas 29.6% (+/- 0.9) 30.0% (+/- 1.3) 29.1% (+/- 1.1) 29.1% (+/- 0.9) 41.1% (+/- 5.1) 30.5% (+/- 3.9) Kentucky 30.4% (+/- 1.5) 29.6% (+/- 2.2) 31.1% (+/- 2.0) 29.6% (+/- 1.5) 43.1% (+/- 7.7) 22.2% (+/- 11.3) Louisiana 33.4% (+/- 1.5) 33.1% (+/- 2.4) 33.9% (+/- 1.8) 31.1% (+/- 1.8) 39.3% (+/- 3.0) 37.5% (+/- 8.8) Maine 27.8% (+/- 1.1) 28.1% (+/- 1.6) 27.6% (+/- 1.4) 27.9% (+/- 1.1) 15.3% (+/- 10.7) 30.3% (+/- 12.3) Maryland 28.3% (+/- 1.4) 28.9% (+/- 2.3) 27.9% (+/- 1.8) 26.0% (+/- 1.6) 37.9% (+/- 3.2) 20.9% (+/- 7.0) Massachusetts 22.7% (+/- 1.0) 24.2% (+/- 1.5) 21.5% (+/- 1.2) 22.2% (+/- 1.1) 32.4% (+/- 4.7) 31.0% (+/- 4.1) Michigan 31.3% (+/- 1.3) 31.9% (+/- 2.0) 30.7% (+/- 1.8) 29.8% (+/- 1.5) 40.9% (+/- 4.2) 36.7% (+/- 8.6) Minnesota 25.7% (+/- 1.1) 28.4% (+/- 1.6) 22.9% (+/- 1.4) 25.9% (+/- 1.1) 28.4% (+/- 5.9) 31.6% (+/- 7.8) Mississippi 34.9% (+/- 1.4) 32.4% (+/- 2.2) 37.4% (+/- 1.9) 30.7% (+/- 1.7) 42.9% (+/- 2.7) 26.8% (+/- 10.3) Missouri 30.3% (+/- 1.7) 29.8% (+/- 2.6) 30.8% (+/- 2.2) 29.4% (+/- 1.8) 39.3% (+/- 6.2) 27.8% (+/- 13.3) Montana 24.6% (+/- 1.4) 25.9% (+/- 2.0) 23.4% (+/- 1.8) 24.2% (+/- 1.4) NA 22.5% (+/- 9.6) Nebraska 28.4% (+/- 0.8) 29.3% (+/- 1.3) 27.6% (+/- 1.2) 28.3% (+/- 0.9) 32.9% (+/- 5.4) 29.8% (+/- 4.1) Nevada 24.5% (+/- 2.1) 25.6% (+/- 3.1) 23.5% (+/- 2.8) 22.0% (+/- 2.1) 31.2% (+/- 8.3) 29.2% (+/- 6.1) New Hampshire 26.2% (+/- 1.5) 28.1% (+/- 2.4) 24.2% (+/- 1.9) 26.5% (+/- 1.6) NA 22.9% (+/- 14.5) New Jersey 23.7% (+/- 1.1) 25.5% (+/- 1.7) 21.9% (+/- 1.4) 23.1% (+/- 1.3) 31.6% (+/- 3.4) 27.2% (+/- 3.3) New Mexico 26.3% (+/- 1.3) 26.4% (+/- 1.9) 26.4% (+/- 1.6) 22.6% (+/- 1.7) 23.9% (+/- 10.0) 30.0% (+/- 2.1) New York 24.5% (+/- 1.4) 25.3% (+/- 2.1) 23.9% (+/- 1.7) 23.7% (+/- 1.7) 32.6% (+/- 4.2) 26.3% (+/- 3.9) North Carolina 29.1% (+/- 1.5) 28.3% (+/- 2.2) 30.0% (+/- 1.9) 26.2% (+/- 1.6) 40.8% (+/- 3.8) 29.0% (+/- 6.8) North Dakota 27.8% (+/- 1.6) 30.1% (+/- 2.4) 25.4% (+/- 2.1) 26.9% ( +/- 1.6) NA NA Ohio 29.6% (+/- 1.4) 31.7% (+/- 2.1) 27.6% (+/- 1.7) 29.2% ( +/- 1.5) 34.0% (+/- 4.7) 32.2% (+/- 11.6) Oklahoma 31.1% (+/- 1.4) 30.6% (+/- 2.2) 31.5% (+/- 1.8) 30.3% ( +/- 1.6) 34.8% (+/- 6.5) 28.7% (+/- 6.3) Oregon 26.7% (+/- 1.6) 26.3% (+/- 2.4) 27.3% (+/- 2.1) 26.1% ( +/- 1.5) NA 28.8% (+/- 8.2) Pennsylvania 28.6% (+/- 1.3) 29.6% (+/- 1.9) 27.7% (+/- 1.6) 28.0% ( +/- 1.3) 36.0% (+/- 4.7) 32.9% (+/- 7.6) Rhode Island 25.4% (+/- 1.6) 27.7% (+/- 2.5) 23.4% (+/- 1.9) 24.9% ( +/- 1.7) 35.2% (+/- 9.8) 26.5% (+/- 5.6) South Carolina 30.8% (+/- 1.3) 28.5% (+/- 2.0) 33.1% (+/- 1.7) 27.0% ( +/- 1.5) 42.4% (+/- 2.8) 25.0% (+/- 8.5) South Dakota 28.1% (+/- 1.9) 29.9% (+/- 2.9) 26.3% (+/- 2.5) 26.7% ( +/- 2.0) NA 40.0% (+/- 15.1) Tennessee 29.2% (+/- 2.5) 28.0% (+/- 3.8) 30.5% (+/- 3.4) 27.9% ( +/- 2.7) 40.5% (+/- 8.2) NA Texas 30.4% (+/- 1.4) 31.0% (+/- 2.1) 30.0% (+/- 1.9) 27.1% ( +/- 1.7) 39.6% (+/- 5.1) 34.5% (+/- 2.7) Utah 24.4% (+/- 1.1) 25.8% (+/- 1.6) 22.9% (+/- 1.4) 24.4% ( +/- 1.1) 29.0% (+/- 14.3) 24.2% (+/- 4.0) Vermont 25.4% (+/- 1.4) 27.3% (+/- 2.2) 23.6% (+/- 1.8) 25.4% ( +/- 1.4) NA 23.5% (+/- 14.4) Virginia 29.2% (+/- 1.7) 29.7% (+/- 2.6) 28.6% (+/- 2.4) 27.6% ( +/- 1.9) 37.8% (+/- 4.8) 31.4% (+/- 9.4) Washington 26.5% (+/- 1.2) 28.0% (+/- 1.9) 25.1% (+/- 1.6) 27.1% ( +/- 1.4) 39.5% (+/- 10.3) 27.9% (+/- 5.0) West Virginia 32.4% (+/- 1.6) 30.7% (+/- 2.4) 34.3% (+/- 2.1) 32.4% ( +/- 1.6) 34.2% (+/- 10.8) 29.1% (+/- 14.7) Wisconsin 27.7% (+/- 2.0) 29.4% (+/- 2.9) 26.1% (+/- 2.7) 26.8% ( +/- 2.0) 44.0% (+/- 10.8) NA Wyoming 25.0% (+/- 1.6) 26.1% (+/- 2.3) 23.8% (+/- 2.2) 24.9% ( +/- 1.7) NA 25.9% (+/- 6.6) 12 States with the Highest Obesity Rates Percentage of Adult Obesity Rank State (Based on 2011 Data, Including Confidence Intervals) 1 Mississippi 34.9% (+/- 1.4) 2 Louisiana 33.4% (+/- 1.5) 3 West Virginia 32.4% (+/- 1.6) 4 Alabama 32.0% (+/- 1.5) 5 Michigan 31.3% (+/- 1.3) 6 Oklahoma 31.1% (+/- 1.4) 7 Arkansas 30.9% (+/- 2.2) 8 (tie) Indiana 30.8% (+/- 1.4) 8 (tie) South Carolina 30.8% (+/- 1.3) 10 (tie) Kentucky 30.4% (+/- 1.5) 10 (tie) Texas 30.4% (+/- 1.4) Note: For rankings, 1 = Highest rate of obesity. States with the Lowest Obesity Rates Percentage of Adult Obesity Rank State (Based on 2011 Data, Including Confidence Intervals) 51 Colorado 20.7% (+/- 1.1) 50 Hawaii 21.8% (+/- 1.5) 49 Massachusetts 22.7% (+/- 1.0) 47 (tie) D.C. 23.7% (+/- 1.9) 47 (tie) New Jersey 23.7% (+/- 1.1) 46 California 23.8% (+/- 0.9) 45 Utah 24.4% (+/- 1.1) 42 (tie) Connecticut 24.5% (+/- 1.5) 42 (tie) Nevada 24.5% (+/- 2.1) 42 (tie) New York 24.5% (+/- 1.4) Note: For rankings, 51 = Lowest rate of obesity. 13 PAST OBESITY TRENDS* AMONG U.S. ADULTS BRFSS, 1991, 1993-1995,1998-2000, and 2008- (*BMI >30, or about 30lbs overweight for 5’4” 2010 Combined Data person) 1991 WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA FL AK HI 1993–1995 Combined Data WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA FL AK HI 1998–2000 Combined Data WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA n No Data n <10% FL n >10% & <15% AK HI n >15% & <20% n >20% 14 RATES AND RANKINGS METHODOLOGY30 The analysis in F as in Fat compares data from the Behavioral These are making survey calls to cell-phone numbers and Risk Factor Surveillance System (BRFSS), the largest phone adopting a new weighting method: survey in the world. n The first change is including and then growing the number of BRFSS is the largest ongoing telephone health survey in the interview calls made to cell phone numbers. Estimates today world. It is a state-based system of health surveys established are that 3 in 10 U.S. households have only cell phones. by CDC in 1984. BRFSS completes more than 400,000 adult n The second is a statistical measurement change, which interviews each year. For most states, BRFSS is their only involves the way the data are weighted to better match the source of population-based health behavior data about chronic demographics of the population in the state. disease prevalence and behavioral risk factors. The new methodology means the BRFSS data will better BRFSS surveys a sample of adults in each state to get information represent lower-income and racial and ethnic minorities, as on health risks and behaviors, health practices for preventing well as populations with lower levels of formal education.  The disease, and healthcare access mostly linked to chronic disease size and direction of the effects will vary by state, the behavior and injury. The sample is representative of the population of under study, and other factors. Although generalizing is each state. difficult because of these variables, it is likely that the changes Washington, D.C., is included in the rankings because CDC in methods will result in somewhat higher estimates for the provides funds to the city to conduct a survey in an equivalent occurrence of behaviors that are more common among way to the states. younger adults and to certain racial and ethnic groups. The data are based on telephone surveys by state health The change in methodology makes direct comparisons to past departments, with assistance from CDC. Surveys ask data difficult. people to report their weight and height, which is used to In prior years, this report has included racial, ethnic and calculate BMI. Experts say rates of overweight and obesity gender breakdowns by state. However, because there is only are probably slightly higher than shown by the data because one year of data available using the new methodology, the people tend to underreport their weight and exaggerate sample sizes for some states are too small to reliably provide their height.31 these breakdowns in this year’s report. BRFSS made two changes in methodology for its 2011 dataset More information on the methodology is available in Appendix B. to make the data more representative of the total population. Definitions of Obesity and Overweight Obesity is defined as an excessively high amount of body fat or adipose tissue in relation to lean body mass.32,33 Overweight refers to increased body weight in relation to height, which is then compared to a standard of acceptable weight.34 An adult is considered obese if his or her body mass index (BMI), a calculation based on an individual’s weight and height, is 30 or higher. The equation is: BMI = (Weight in pounds) x 703 (Height in inches) x (Height in inches) Adults with a BMI of 25 to 29.9 are considered overweight. The National Institutes of Health (NIH) adopted a lower optimal weight threshold in June 1998. Previously, the federal government defined overweight as a BMI of 28 for men and 27 for women. On the basis of 2000 CDC growth charts, children and youth at or above the 95th percentile were defined as “overweight,” while children at or above the 85th percentile but below the 95th percentile were defined as “at risk of overweight.” However, in 2007, an expert committee recommended using the same cut points but changing the terminology by replacing “overweight” with “obese” and “at risk of overweight” with “overweight.” The committee also added an additional cut point — BMI at or above the 99th percentile — to define “severe obesity.”35 BMI is considered an important measure for understanding population trends. For individuals, it may be less accurate and should be used alongside other measures of risk, including waist size, waist-to- hip ratio, blood pressure, cholesterol level, and blood sugar, among others.36 15 OBESITY AROUND THE WORLD New information from the Organization for and France only increased by 2 percent to 3 Economic Cooperation and Development percent.39 But in Canada, Ireland and the United (OECD) shows that, while more than half of States, rates continued to increase, by up to adults are either overweight or obese in the 5 percent. During the last decade childhood majority of OECD countries, the rate of growth obesity rates have leveled out in England, France, slowed or stopped in many countries over the South Korea and the United States.40 last decade.37 In England almost a quarter of the Data also showed consistent disparities in obesity population is obese, up to 18 percent in Hungary rates across many countries. Women with less are considered obese, and almost 15 percent in education were two to three times more likely Spain and Ireland are obese.38 to be overweight or obese than women with In England, Hungary, Italy, South Korea and higher education levels, and the trend stayed Switzerland, obesity rates either stopped consistent throughout the decade with no im- growing or slowed significantly, and Spain provements made to remedy the disparity.41 SOCIOECONOMICS AND OBESITY An analysis of the 2008-2010 BRFSS data look- 21.5 percent of those who graduated from ing at income, level of schooling completed and college or technical college. obesity finds strong correlations between obesity n More than 33 percent of adults who earn less and income and between obesity and education: than $15,000 per year were obese, compared n Nearly 33 percent of adults who did not grad- with 24.6 percent of those who earned at uate high school were obese, compared with least $50,000 per year.42 B. CHILDHOOD AND YOUTH OBESITY AND OVERWEIGHT RATES 1. Study of Children Ages 10–17 (2007) The most recent data for childhood statistics on they are the only source of comparative state-by- a state-by-state level are from the 2007 National state data for children. Survey of Children’s Health (NSCH).43 The next Nine of the 10 states with the highest rates of NSCH release is expected in late 2012. According obese children are in the South. In 2003, when to the 2007 study, obesity rates for children ages the last NSCH was conducted, only Washington, 10–17, defined as BMI greater than the 95th D.C., and three states — Kentucky, Tennessee percentile for age group, ranged from a low of and West Virginia — had childhood obesity 9.6 percent in Oregon to a high of 21.9 percent rates higher than 20 percent. Four years later, in Mississippi. The NSCH study is based on a in 2007, six more states had childhood obesity survey of parents in each state. The data are rates over 20 percent: Arkansas, Georgia, Illi- derived from parental reports, so they are not as nois, Louisiana, Mississippi and Texas. reliable as measured data, such as NHANES, but 16 Obese 10- to 17-Year-Olds, 2007 NSCH WA MT ND MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA n No Data n <10% FL n >10% & <15% AK n >15% & <20% HI n >20% & <25% n >25% & <30% n >30% Source: National Survey on Children’s Health, 2007. States with the Highest Rates of Obese 10- to 17-year-olds Percentage of Obese 10- to 17-year-olds Rank States (95 percent Confidence Intervals) 1 Mississippi 21.9% (+/- 3.5) 2 Georgia 21.3% (+/- 5.1) 3 Kentucky 21.0% (+/- 3.5) 4 (tie) Illinois 20.7% (+/- 3.6) 4 (tie) Louisiana 20.7% (+/- 4.0) 6 Tennessee 20.6% (+/- 3.7) 7 (tie) Arkansas 20.4% (+/- 3.6) 7 (tie) Texas 20.4% (+/- 5.0) 9 D.C. 20.1% (+/- 3.9) 10 West Virginia 18.9% (+/- 3.2) *Note: For rankings, 1 = Highest rate of childhood obesity. Eight of the states with the lowest rates of obese 10- to 17-year-olds are in the West. States with the Lowest Rates of Obese 10- to 17-year-olds Percentage of Obese 10- to 17-year-olds Rank States (95 percent Confidence Intervals) 51 Oregon 9.6% (+/- 2.7) 50 Wyoming 10.2% (+/- 2.7) 48 (tie) Washington 11.1% (+/- 3.4) 48 (tie) Minnesota 11.1% (+/- 3.0) 46 (tie) Iowa 11.2% (+/- 2.7) 46 (tie) Hawaii 11.2% (+/- 2.8) 44 (tie) Utah 11.4% (+/- 3.5) 44 (tie) North Dakota 11.4% (+/- 2.5) 42 (tie) Montana 11.8% (+/- 2.8) 42 (tie) Idaho 11.8% (+/- 2.7) *Note: For rankings, 51 = Lowest rate of childhood obesity. 17 2. Study of High School Students The Youth Risk Behavior Surveillance System ducted in 43 states, found a range in the percent- (YRBSS) includes both national and state surveys age of high school students who were physically that provide data on adolescent obesity and over- active for at least 60 minutes per day seven days a weight rates, most recently in 2011.44 The infor- week, from a high of 33.1 percent in Oklahoma mation from the YRBSS is based on self-reported to a low of 20.8 percent in Utah, with a median information. According to the national survey, 13 prevalence of 25.8 percent. percent of high school students were obese and The latest state surveys also found a range of 15.2 percent were overweight.45 There has been obesity levels: a low of 7.3 percent in Colorado an upward trend from 1999 to 2011 in the preva- to a high of 17.0 percent in Alabama, with a me- lence of students nationwide who were obese dian prevalence of 12.0 percent. Overweight (10.6 percent to 13 percent) and who were over- prevalence among high school students ranged weight (14.2 percent to 15.2 percent).46 Students from a low of 10.7 percent in Colorado to a high also reported on whether or not they participated of 19.5 percent in Louisiana, with a median in at least 60 minutes of physical activity every day prevalence of 14.7 percent. of the week. The most recent state surveys, con- PERCENT OF OBESE HIGH SCHOOL STUDENTS — Selected U.S. States, Youth Risk Behavior Survey, 2011 WA 9 11 MN 10 12 10 10 OR 9 12 11 12 11 13 10 12 PA 11 12 15 15 13 NV 9 11 7 10 MO 15 12 17 11 12 CA 17 15 13 13 15 11 13 16 17 15 16 16 n No Data 12 n <10% 12 n 10% – 14% 13 n 15% – 19% Source: YBRS. Trend maps from 2003-2011 are available at: http://www.cdc.gov/healthyyouth/obesity/obesity-youth.htm. Percentage of Obese and Overweight U.S. High School Students by Sex Obese Overweight Female 9.8% 15.4% Male 16.1% 15.1% Total 13.0% 15.2% Percentage of Obese and Overweight U.S. High School Students by Race/Ethnicity Obese Overweight White* 11.5% 14.2% Black* 18.2% 16.2% Hispanic 14.1% 17.4% Total** 13.0% 15.2% Notes: *Non-Hispanic. **Other race/ethnicities are included in the total but are not presented separately. 18 Percentage of Obese and Overweight U.S. High School Students by Sex and Race/Ethnicity Obese Overweight Female Male Female Male White* 7.7% 15.0% 13.8% 14.7% Black* 18.6% 17.7% 19.6% 12.8% Hispanic 8.6% 19.2% 18.0% 16.9% Total** 9.8% 16.1% 15.4% 15.1% Notes: *Non-Hispanic. **Other race/ethnicities are included in the total but are not presented separately. 3. Study of Children from Lower-Income Families (2010) The Pediatric Nutrition Surveillance Survey The prevalence of obesity among children from (PedNSS), which examines children between lower-income families increased from 12.7 per- the ages of 2 and 5 from lower-income families, cent in 1999 to 14.4 percent in 2010, although found that 14.4 percent of this group is obese, rates have remained stable since 2003. The high- compared with 12.1 percent for all U.S. children est obesity rates were seen among American In- of a similar age.47 The data for PedNSS is based dian and Alaska Native children (21.1 percent) on actual measurements rather than self reports. and Latino children (17.6 percent). 4. Physical Inactivity in Adults Physical inactivity in adults reflects the number Mississippi, the state with the highest rate of survey respondents who reported not engag- of obesity, also had the highest reported ing in physical activity or exercise during the pre- percentage of inactivity at 36 percent. vious 30 days other than doing their regular jobs. States with the Highest Physical Inactivity Rates, 2011 Percentage of Adult Physical Inactivity Rank State Obesity Ranking (Based on 2011 Data, Including Confidence Intervals) 1 Mississippi 36.0% (+/- 1.5) 1 2 Tennessee 35.2% (+/- 2.7) 15 (tie) 3 West Virginia 35.1% (+/- 1.6) 3 4 Louisiana 33.8% (+/- 1.5) 2 5 Alabama 32.6% (+/- 1.6) 4 6 Oklahoma 31.2% (+/- 1.4) 6 7 Arkansas 30.9% (+/- 2.1) 7 8 Kentucky 29.4% (+/- 1.5) 10 (tie) 9 Indiana 29.3% (+/- 1.4) 8 (tie) 10 Missouri 28.5% (+/- 1.6) 12 *Note: For rankings, 1=Highest rate of physical inactivity Colorado, the state with the lowest rate of adult obesity, also had the lowest reported rate of physical inactivity at 16.5 percent. States with the Lowest Physical Inactivity Rates, 2011 Percentage of Adult Physical Inactivity Rank State Obesity Ranking (Based on 2011 Data, Including Confidence Intervals) 51 Colorado 16.5% (+/- 1.8) 51 50 Utah 18.9% (+/- 1.0) 45 49 California 19.1% (+/- 0.9) 46 48 Oregon 19.7% (+/- 1.5) 31 47 D.C. 19.8% (+/- 1.8) 47 (tie) 46 Vermont 21.0% (+/- 1.3) 37 (tie) 45 Hawaii 21.3% (+/- 1.5) 50 44 Idaho 21.4% (+/- 1.7) 30 43 Minnesota 21.8% (+/- 1.0) 36 42 Washington 21.9% (+/- 1.2) 33 *Note: For rankings, 51 = Lowest rate of physical inactivity. 19 D. Type 2 Diabetes and Hypertension in Adults Obesity and physical inactivity have been linked top 10 for obesity rates; and 7 of the 10 states to a range of chronic diseases, including dia- with the highest hypertension rates are also in betes and hypertension. Seven of the 10 states the top 10 for obesity. with the highest diabetes rates are also in the 1. Type 2 Diabetes All 10 of the states with the highest rates of type 2 diabetes are in the South. States with the Highest Rates of Adults with Type 2 Diabetes, 2011 Percentage of Adult Diabetes Rank State Obesity Ranking (Based on 2011 Data, Including Confidence Intervals) 1 Mississippi 12.3% (+/- 0.8) 1 2 West Virginia 12.1% (+/- 1.0) 3 3 South Carolina 12.0% (+/- 0.8) 8 (tie) 4 Alabama 11.8% (+/- 0.9) 4 5 Louisiana 11.8% (+/- 0.9) 2 6 (tie) Arkansas 11.2% (+/- 1.2) 7 6 (tie) Tennessee 11.2% (+/- 1.5) 15 (tie) 8 Oklahoma 11.1% (+/- 0.8) 6 9 (tie) Kentucky 10.8% (+/- 0.8) 10 (tie) 9 (tie) North Carolina 10.8% (+/- 0.8) 17 *Note: For rankings, 1 = Highest rate of type 2 diabetes. THE DIABETES BELT In the 1960s researchers first identified the Tennessee, Texas, Virginia, West Virginia, and Southeastern United States as the “stroke belt,” all of Mississippi.48 The demographics of these since strokes were much more frequent in 644 counties vary greatly from those of the that region than the rest of the country. Now, overall country. They have a high percentage of scientists are focusing on a “diabetes belt,” made Blacks, and, not surprisingly, a high number of up of 644 counties in 15 mostly Southern states. people who are obese and lead sedentary lives.49 This belt includes parts of Alabama, Arkansas, Policymakers hope to use this new information to Florida, Georgia, Kentucky, Louisiana, North target resources to those who most need help. Carolina, Ohio, Pennsylvania, South Carolina, 2. Hypertension All 10 states with the highest rates of hypertension are also in the South. States with the Highest Rates of Adult Hypertension, 2011 Percentage of Adult Hypertension Rank State Obesity Ranking (Based on 2011 Data, Including Confidence Intervals) 1 Alabama 40.0% (+/- 1.6) 4 2 Mississippi 39.2% (+/- 1.4) 1 3 Tennessee 38.6% (+/- 2.6) 15 (tie) 4 Louisiana 38.3% (+/- 1.4) 2 5 Kentucky 37.9% (+/- 1.5) 10 (tie) 6 West Virginia 37.1% (+/- 1.6) 3 7 South Carolina 36.4% (+/- 1.3) 8 (tie) 8 Arkansas 35.7% (+/- 2.1) 7 9 Oklahoma 35.5% (+/- 1.4) 6 10 Delaware 34.6% (+/- 1.9) 19 *Note: For rankings, 1 = Highest rate of hypertension. 20 e. Fruit and Vegetable Consumption Fruit and vegetable consumption, as part of a The number of individuals who reported eating healthy diet, is important for weight manage- fruits and vegetables five or more times a day ment, optimal child growth, and chronic dis- was the lowest in West Virginia (7.9 percent) ease prevention. Seven of the 10 states with the and was the highest in Washington, D.C. (25.6 highest rates of obesity were also in the bottom percent). The data are from survey responses 10 for fruit and vegetable consumption. to the 2011 BRFSS survey. States with the Lowest Adult Fruit and Vegetable Consumption, 2011 Percentage of Adult Fruit and Vegetable Consumption Obesity Rank- Rank State (Based on 2011 Data, Including Confidence Intervals) ing 1 West Virginia 7.9% (+/- 0.9) 3 2 Louisiana 8.2% (+/- 0.9) 2 3 Oklahoma 9.8% (+/- 0.9) 6 4 Mississippi 10.3% (+/- 1.0) 1 5 (tie) Kentucky 10.6% (+/- 1.0) 10 (tie) 5 (tie) Tennessee 10.6% (+/- 1.9) 15 (tie) 7 South Dakota 11.0% (+/- 1.2) 23 8 (tie) Alabama 12.5% (+/- 1.1) 4 8 (tie) South Carolina 12.5% (+/- 0.9) 8 10 Delaware 12.9% (+/- 1.4) 19 Note: For rankings, 1 = Lowest rate of fruit and vegetable consumption. States with the Highest Adult Fruit and Vegetable Consumption, 2011 Percentage of Adult Fruit and Vegetable Consumption Obesity Rank- Rank State (Based on 2011 Data, Including Confidence Intervals) ing 51 D.C. 25.6% (+/- 2.1) 47 (tie) 50 California 24.4% (+/- 0.9) 46 49 Vermont 22.7% (+/- 1.3) 37 (tie) 48 New Hampshire 22.5% (+/- 1.5) 35 47 Oregon 22.3% (+/- 1.4) 31 46 Arizona 21.4% (+/- 2.0) 40 45 Connecticut 20.8% (+/- 1.4) 42 (tie) 44 New York 19.9% (+/- 1.3) 42 (tie) 43 Rhode Island 19.8% (+/- 1.4) 37 (tie) 42 Hawaii 19.7% (+/- 1.4) 50 Note: For rankings, 51 = Highest rate of fruit and vegetable consumption. 21 Two Futures for America’s Health 2 Section T FAH and RWJF commissioned the National Heart Forum (NHF) to con- duct a modeling study to examine how obesity rates in states could change if trends continued on their current trajectory, including the potential impact on obesity-related diseases and costs by 2030. The analysis also looked at how disease rates and costs could be affected by lowering the average BMI in the state by only 5 percent in each state. Currently, more than 35 percent of American could be spared from preventable diseases and adults are obese.50 Individuals with a BMI of each state could save billions in health care 30 or higher are considered obese. The report costs. For an adult of average weight, reducing found if current trends continue, by the year BMI by 1 percent is equivalent to a weight loss 2030, more than 44 percent of adults could be of around 2.2 pounds.51 obese, which could lead to major increases in The analysis concluded, therefore, that there obesity-related disease rates and health care are two potential futures for America’s health. costs. But, if states could reduce the average adult BMI by 5 percent, millions of Americans Background The study is based on a peer-reviewed model The NHF is an international center for the developed by researchers at the NHF and prevention of avoidable chronic diseases, including used for the basis of an analysis, “Health and coronary heart disease, stroke, cancer and Economic Burden of the Projected Obesity diabetes. The organization is an alliance of 65 Trends in the USA and the UK,” published in charitable organizations in the United Kingdom, 2011 in The Lancet.52  The full methodology is including leading policy research experts on available in Appendix C. chronic disease prevention and promotes consensus-based healthy public policy. 23 Peer-Reviewed Projections of Future Trends The analysis is based on a model developed In addition, they projected baseline estimates for:54 by researchers at the National Heart Forum. n The number of new cases of diabetes could Micro Health Simulations used the model in a be 7.9 million (+/- 1.6 million) per year, peer reviewed study, “Health and Economic which means it could be as low as 6.3 mil- Burden of the Projected Obesity Trends in lion or as high as 9.5 million; the [United States and the United Kingdom],” published in 2011 in The Lancet.53  The full n The number of new cases of chronic heart dis- methodology is available in Appendix C. ease and stroke could be 6.8 million (+/- 1.5 million) per year, which means it could be as All models have limitations in forecasting the low as 5.3 million or as high as 8.3 million; and future, but they help predict the trajectory of trends based on past data. Trends can, of n The number of new cases of cancer could course, change significantly over time for a be 0.5 million (+/- 0.1 million) per year, variety of reasons. However, having a sense which means it could be as low as 0.4 mil- of potential scenarios is particularly helpful lion or as high as 0.6 million. to understand patterns, such as growth rates The projections in the state-by-state analysis for diseases and costs projections, which can featured in the F as in Fat report are considered inform policy priorities and decisions. to be marginally more accurate than those re- The NHF study published in The Lancet in ported in the national study, because the state- 2011 developed national projections for by-state study is based on data from the BRFSS obesity and the potential growth in related instead of NHANES. BRFSS provides more data disease rates and costs between 2010 and points than NHANES (10 versus seven). In other 2030, using data from the National Health and words, more data points enables researchers to Nutrition Examination Survey (NHANES). estimate projections more precisely. They found the number of obese Americans The modeling study also reflects adjustments of could grow from 32 percent, in 2011, to data to correct for self-reporting bias in BRFSS.55 around 50 percent (+/- 5) in 2030, with the These findings are similar to a 2012 study in potential estimated low rate would be 45 and the American Journal of Preventive Medicine. the high rate is 55. The study found that by 2030, 42 percent of Based on the predicted rise in obesity, they U.S. adults will be obese.56 This study also found the baseline potential growth in obesity found that the rate of severe obesity will costs could be $66 billion (+/- 45 billion). double by 2030, when more than 10 percent Within the potential range, it could be as low of adults will be considered severely obese.57 as $20 billion or as high as $110 billion. The projected increase in obesity is estimated to cost the United States $550 billion in health spending between now and 2030.58 24 A. KEY FINDINGS Obesity in 2030 If obesity rates continue on their current track, However, if states could reduce average adult BMIs in 2030, more than 60 percent of adults in Amer- by 5 percent, no state would have an obesity rate ica could be obese in 13 states; more than half above 60 percent. More than half of Americans of adults could be obese in 39 states; and more would be obese in 24 states; two states would have than 44 percent could be obese in all 50 states. rates under 40 percent (Alaska at 39.4 percent and Colorado at 39 percent); and Washington, D.C. would be below 30 percent (29.1 percent). 2030: Adult WA ND Obesity Rates MT MN n <35% VT ME n <35% & <40% if the Current OR ID WY SD WI MI NY NH n >40% & <45% Trajectory NE IA PA MA RI n >45% & <50% Continues NV UT CO IL IN OH WV NJ DE CT n >50% & <55% KS MO MD CA KY VA DC n >55% & <60% OK AR TN NC n >60% & <65% AZ NM MS AL SC n >65% GA TX LA FL AK HI 2030: Adult WA ND Obesity Rates if MT MN VT ME Average BMI is OR ID WY SD WI MI NY NH Reduced by NE IA PA MA RI n <35% 5 Percent NV UT CO IL IN OH WV NJ DE CT n <35% & <40% KS MO KY VA MD DC n >40% & <45% CA OK TN NC n >45% & <50% AR AZ NM SC n >50% & <55% MS AL GA TX LA n >55% & <60% n >60% & <65% FL n >65% AK HI Potential WA ND Percent Increase MT MN VT ME in Obesity Rates OR ID WY SD WI MI NY NH 2010-2030 NE IA PA MA RI IL IN OH CT NV UT CO KS MO WV NJ DE n <80% MD CA KY VA DC n >80% & <90% OK AR TN NC n >90% & <100% AZ NM MS AL SC n >100% & <110% GA TX LA n >110% & <120% n >120% & <130% AK FL n >130% HI 25 Rates and Rankings 2030 Obesity rates in 2030 Obesity rates in 2030 if states State Rank Rank on current track reduce average adult BMI by 5% Alabama 62.6% 6 55.1% 8 Alaska 45.6% 49 39.4% 49 Arizona 58.8% 16 51.8% 17 Arkansas 60.6% 10 53.4% 11 California 46.6% 46 40.5% 47 Colorado 44.8% 50 39.0% 50 Connecticut 46.5% 47 40.5% 47 Delaware 64.7% 3 56.4% 4 DC 32.6% 51 29.1% 51 Florida 58.6% 18 51.1% 19 Georgia 53.6% 35 47.5% 33 Hawaii 51.8% 38 45.5% 38 Idaho 53.0% 37 46.9% 37 Illinois 53.7% 34 47.5% 33 Indiana 56.0% 27 49.5% 25 Iowa 54.4% 31 47.6% 32 Kansas 62.1% 7 55.1% 8 Kentucky 60.1% 13 53.2% 15 Louisiana 62.1% 7 55.4% 7 Maine 55.2% 29 49.0% 29 Maryland 58.8% 16 52.2% 16 Massachusetts 48.7% 43 42.4% 43 Michigan 59.4% 15 53.4% 11 Minnesota 54.7% 30 47.5% 33 Mississippi 66.7% 1 59.9% 1 Missouri 61.9% 9 55.5% 5 Montana 53.6% 35 47.4% 36 Nebraska 56.9% 23 50.6% 21 Nevada 49.6% 41 43.8% 41 New Hampshire 57.7% 20 50.8% 20 New Jersey 48.6% 44 42.3% 44 New Mexico 54.2% 32 48.8% 30 New York 50.9% 39 44.5% 40 North Carolina 58.0% 19 51.4% 18 North Dakota 57.1% 22 49.4% 26 Ohio 59.8% 14 53.5% 10 Oklahoma 66.4% 2 58.6% 2 Oregon 48.8% 42 43.4% 42 Pennsylvania 56.7% 24 50.4% 23 Rhode Island 53.8% 33 48.4% 31 South Carolina 62.9% 5 55.5% 5 South Dakota 60.4% 11 53.3% 14 Tennessee 63.4% 4 57.4% 3 Texas 57.2% 21 50.4% 23 Utah 46.4% 48 40.6% 46 Vermont 47.7% 45 42.1% 45 Virginia 49.7% 40 44.7% 39 Washington 55.5% 28 49.1% 28 West Virginia 60.2% 12 53.4% 11 Wisconsin 56.3% 26 49.4% 26 Wyoming 56.6% 25 50.5% 22 26 DISEASE RATES Nationally, obesity could contribute to more n Coronary Heart Disease and Stroke: Between than 6 million cases of type 2 diabetes, 5 million 16,730 in Utah to 35,519 in West Virginia (av- cases of coronary heart disease and stroke, and erage for all states: 26,573) more than 400,000 cases of cancer in the next n ypertension: Between 17,790 in Utah to H two decades, according to The Lancet study’s 30,508 in Maine (average for all states: 24,923) conservative estimates.59 n Arthritis: Between 12,504 in Utah to 18,725 As the number of obese individuals grows, the seg- in Maine (average for all states: 16,152) ment of the population that is currently at risk for the highest incidence of health problems related n besity-Related Cancer: Between 2,468 in Utah O to obesity exponentially increases their risk of de- to 4,897 in Maine (average for all states: 3,781) veloping those conditions. This report examined However, if states could reduce the average BMI the potential growth of five of the highest-cost and by 5 percent by 2030, thousands of cases of type highest-incidence health problems related to obe- 2 diabetes, coronary heart disease, stroke, hyper- sity — type 2 diabetes, coronary heart disease and tension and arthritis (except Alaska and Utah) stroke, hypertension, arthritis and obesity-related could be prevented per 100,000 people in nearly cancer. For instance, approximately 33 percent each state, and more than 100 cases of obesity- of Americans (79 million people) are currently related cancer per 100,000 people could be pre- pre-diabetic, which means they have prolonged vented per state. or uncontrolled elevated blood sugar levels that can contribute to the development of diabetes. For every 100,000 Americans, the number of These 79 million Americans are at a tipping point. individuals who could avoid these serious health As more Americans become obese, more people problems range from: who are currently maintaining blood sugar levels n Type 2 Diabetes: Between 1,810 in Utah to below the level of full-blown diabetes will cross 3,216 in West Virginia over that line. Twenty years ago, only 7.8 million Americans had been diagnosed with diabetes. n Coronary Heart Disease and Stroke: Between Currently, around 25.8 million Americans have 1,339 in Utah to 2,898 in West Virginia diabetes, and if trends continue on their current n Hypertension: Between 1,427 in Utah to track, in 2030, more than 31 million Americans 2,512 in Maine will have diabetes. n Arthritis: Between 849 in Utah to 1,382 in The analysis found that if we continue on cur- Maine rent trajectories by 2030, for every 100,000 Americans, the number of additional individu- n Obesity-Related Cancer: Between 101 in als that could develop the top five obesity-re- Utah to 277 in Maine lated health conditions (new cases) range from: More information about these five top obesity- n ype 2 Diabetes: Between 8,658 in Utah T related health problems is provided in the fol- to 15,208 in West Virginia (average for all lowing section. states: 12,127) 27 Health Care Costs The national analysis found combined medical n 6 states and Washington, D.C., could expect 1 costs associated with treating preventable obe- increases between 15 percent and 20 percent; sity-related diseases are estimated to increase by n 8 states could expect increases between 10 1 between $48 billion and $66 billion per year in percent and 15 percent; and the United States by 2030 — while the loss in economic productivity could be between $390 n nly seven states could have increases lower O billion and $580 billion annually by 2030.60 than 10 percent. In the state-by-state review, the analysis found Many states that currently have lower obesity that if obesity rates continue on their current rates, such as Colorado and New Hampshire, track, obesity-related health care costs are on a stand to see the largest increases in obesity-re- course to increase significantly in most states: lated costs if obesity continues to grow on its current trajectory. n ew Jersey could see an increase of more N than a third (34.5 percent); Reducing average BMI by 5 percent by 2030 could significantly reduce health care costs n ight states could see increases between 20 E around the country. Every state except Florida percent and 30 percent — New Hampshire would save between 6.5 percent and 7.8 percent (28.7 percent), Colorado (28.5 percent), in obesity-related health costs. (The impact on Alaska (25.7 percent), Georgia (24.3 per- Florida, which could see a 2.1 percent reduc- cent), Virginia (23.8 percent), Washington tion, would likely be less significant because of (21.6 percent), Maryland (21.3 percent) and the older demographics in the state.) Vermont (20.3 percent); 28 New Cases by 2030 New Diabetes Rank New Cancer Cases Rank New CHD & Stroke Rank New Hypertension Rank New Arthritis Rank State Cases by 2030 (per by 2030 (per (per Cases by 2030 (per Cases by 2030 (per Cases by 2030 (per (per 100,000) 100,000) 100,000) 100,000) (per 100,000) 100,000) (per 100,000) 100,000) (per 100,000) 100,000) Alabama 13,777 9 4,169 9 30,376 8 26,782 10 17,039 13 Alaska 9,648 49 3,034 50 20,785 50 21,258 50 14,501 50 Arizona 11,239 42 3,358 45 23,405 44 22,356 47 14,942 45 Arkansas 13,000 18 3,950 20 28,548 18 25,512 26 16,484 25 California 10,078 48 3,320 46 22,365 47 22,360 46 14,783 49 Colorado 10,146 47 3,443 43 22,979 46 23,592 43 15,371 44 Connecticut 11,524 37 4,130 12 28,320 20 26,281 17 16,677 20 Delaware 13,360 13 4,217 8 29,936 9 27,039 8 16,922 14 DC 9,346 50 3,288 48 21,229 49 21,989 49 14,892 47 Florida 12,816 19 4,561 3 32,471 3 27,611 5 17,138 9 Georgia 11,405 40 3,311 47 23,032 45 23,286 44 15,519 42 Hawaii 11,031 45 3,791 31 26,121 38 24,174 42 15,486 43 Idaho 11,156 43 3,400 44 23,845 42 22,605 45 14,894 46 Illinois 11,856 34 3,639 41 25,304 41 24,420 38 15,975 36 Indiana 12,497 25 3,737 33 26,801 32 24,925 31 16,181 31 Iowa 12,007 33 3,933 21 28,018 21 24,996 29 16,150 32 Kansas 12,809 20 3,703 38 26,803 31 24,838 34 16,022 35 Kentucky 13,596 10 4,034 16 29,257 14 26,909 9 17,132 10 Louisiana 13,238 14 3,718 36 26,723 34 24,870 33 16,267 30 Maine 14,507 3 4,897 1 34,833 2 30,508 1 18,725 1 Maryland 12,720 21 3,825 30 26,433 37 25,538 25 16,617 24 Massachusetts 11,313 41 4,045 15 27,214 27 25,858 21 16,639 22 Michigan 13,997 5 4,002 19 28,941 15 26,450 15 17,249 8 Minnesota 11,411 39 3,642 40 25,550 40 24,549 36 15,808 39 Mississippi 13,945 6 3,729 35 27,346 24 25,233 28 16,372 27 Missouri 14,032 4 4,016 18 29,291 13 26,373 16 16,918 15 Montana 12,639 22 4,287 7 30,542 6 27,080 7 17,063 11 Nebraska 12,225 30 3,706 37 26,672 35 24,211 41 15,741 41 Nevada 11,443 38 3,670 39 25,796 39 24,361 39 15,806 40 New Hampshire 13,850 8 4,363 5 30,933 5 28,959 3 18,146 3 New Jersey 11,012 46 3,492 42 23,661 43 24,687 35 16,078 34 New Mexico 12,146 31 3,850 28 26,875 29 24,515 37 15,972 37 New York 11,612 36 3,915 23 26,806 30 25,450 27 16,332 28 North Carolina 12,604 24 3,759 32 26,638 36 24,994 30 16,289 29 North Dakota 11,641 35 3,913 25 27,836 22 24,925 31 16,098 33 Ohio 13,851 7 4,079 13 29,441 12 26,742 13 17,058 12 Oklahoma 13,525 12 3,879 27 28,516 19 25,579 23 16,373 26 Oregon 12,078 32 3,922 22 27,245 26 25,555 24 16,666 21 Pennsylvania 13,586 11 4,340 6 31,110 4 27,338 6 17,376 7 Rhode Island 13,215 15 4,149 10 28,655 17 26,754 12 17,497 5 South Carolina 13,156 16 4,023 17 28,886 16 25,993 18 16,687 19 South Dakota 12,278 29 3,737 33 27,013 28 24,317 40 15,844 38 Tennessee 14,673 2 4,066 14 29,625 10 26,778 11 17,449 6 Texas 11,107 44 3,158 49 22,156 48 22,160 48 14,791 48 Utah 8,658 51 2,468 51 16,730 51 17,790 51 12,504 51 Vermont 12,322 28 4,430 4 30,429 7 27,823 4 17,608 4 Virginia 12,607 23 3,890 26 27,309 25 25,976 19 16,780 18 Washington 12,366 27 3,829 29 26,758 33 25,769 22 16,639 22 West Virginia 15,208 1 4,796 2 35,519 1 30,092 2 18,720 2 Wisconsin 12,408 26 3,914 24 27,658 23 25,880 20 16,785 17 Wyoming 13,005 17 4,149 10 29,564 11 26,632 14 16,892 16 29 Total Health Care Costs 2030 Percentage of Potential Rank for Potential Percentage of Potential Potential Savings by 2020 Potential Savings by 2030 Increase in Obesity-Related Increase in Obesity- Savings by 2030 if State State if State Reduced Average if State Reduced Average Health Care Costs by 2030 Related Health Care Reduced Average BMI by 5% (cumulative) BMI by 5% (cumulative) on Current Course Costs by 2030 BMI by 5% Alabama 12% 34th $3,381,000,000 $9,481,000,000 7.1% Alaska 25.7% 4th $573,000,000 $1,530,000,000 6.5% Arizona 11.1% 41st $4,775,000,000 $13,642,000,000 7.5% Arkansas 9.6% 45th $2,157,000,000 $6,054,000,000 7.6% California 15.7% 22nd $28,886,000,000 $81,702,000,000 7.6% Colorado 28.5% 3rd $3,792,000,000 $10,794,000,000 7.1% Connecticut 15.7% 22nd $2,626,000,000 $7,370,000,000 7.0% Delaware 14.0% 28th $701,000,000 $1,912,000,000 7.3% DC 18.8% 15th $364,000,000 $1,026,000,000 6.7% Florida 3.3% 50th $12,541,000,000 $34,436,000,000 2.1% Georgia 24.3% 5th $7,963,000,000 $22,743,000,000 7.7% Hawaii 12.3% 38th $976,000,000 $2,704,000,000 7.1% Idaho 12.0% 36th $1,195,000,000 $3,280,000,000 7.3% Illinois 16.1% 21st $9,852,000,000 $28,185,000,000 7.5% Indiana 13.0% 32nd $5,020,000,000 $13,400,000,000 7.1% Iowa 3.7% 49th $2,059,000,000 $5,702,000,000 7.1% Kansas 11.2% 43rd $2,188,000,000 $5,979,000,000 7.7% Kentucky 17.6% 17th $3,376,000,000 $9,437,000,000 7.3% Louisiana 12.8% 39th $3,657,000,000 $9,839,000,000 7.3% Maine 19.0% 12th $1,019,000,000 $2,870,000,000 7.1% Maryland 21.3% 7th $4,935,000,000 $13,836,000,000 7.6% Massachusetts 19.1% 10th $5,045,000,000 $14,055,000,000 7.2% Michigan 19.0% 12th $8,710,000,000 $24,187,000,000 7.7% Minnesota 15.7% 26th $4,189,000,000 $11,630,000,000 7.3% Mississippi 11.7% 40th $2,270,000,000 $6,120,000,000 6.9% Missouri 13.9% 31st $4,718,000,000 $13,368,000,000 7.9% Montana 13.0% 32nd $715,000,000 $1,939,000,000 6.9% Nebraska 6.7% 47th $1,334,000,000 $3,686,000,000 7.5% Nevada 18.2% 14th $2,095,000,000 $5,921,000,000 7.3% New Hampshire 28.7% 2nd $1,158,000,000 $3,257,000,000 7.1% New Jersey 34.5% 1st $471,000,000 $1,391,000,000 7.4% New Mexico 11.8% 42nd $1,483,000,000 $4,095,000,000 7.3% New York 14.8% 29th $14,097,000,000 $40,017,000,000 7.2% North Carolina 17.6% 17th $7,633,000,000 $21,101,000,000 7.5% North Dakota 1.9% 51st $413,000,000 $1,177,000,000 7.2% Ohio 15.2% 25th $9,628,000,000 $26,328,000,000 7.6% Oklahoma 10.8% 44th $2,755,000,000 $7,444,000,000 7.2% Oregon 17.3% 16th $2,791,000,000 $7,938,000,000 7.3% Pennsylvania 9.1% 46th $8,774,000,000 $24,498,000,000 7.1% Rhode Island 19.9% 11th $855,000,000 $2,478,000,000 7.6% South Carolina 12.6% 35th $3,319,000,000 $9,309,000,000 7.4% South Dakota 3.6% 48th $569,000,000 $1,553,000,000 7.6% Tennessee 17.8% 20th $4,928,000,000 $13,827,000,000 7.6% Texas 17.1% 19th $19,386,000,000 $54,194,000,000 7.7% Utah 13.7% 30th $2,122,000,000 $5,843,000,000 7.8% Vermont 20.3% 9th $487,000,000 $1,376,000,000 7.3% Virginia 23.8% 6th $6,266,000,000 $18,114,000,000 7.4% Washington 21.6% 8th $5,201,000,000 $14,729,000,000 7.4% West Virginia 12.0% 36th $1,346,000,000 $3,638,000,000 6.8% Wisconsin 14.7% 27th $4,148,000,000 $11,962,000,000 7.4% Wyoming 15.6% 24th $389,000,000 $1,088,000,000 7.3% 30 Potential Percent Growth in Obesity-Related Health Care Costs by 2030 if the Current Trajectory Continues (By Percent) WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA FL n <5% AK n >5% & <10% HI n >10% & <15% n >15% & <20% n >20% & <25% n >25% & <30% n >30% Projected Obesity-Related Health Care Costs 2010 to 2030 Predicted BMI-related direct health costs; 0%, 1%, and 5% reduction in absolute BMI 630000 620000 610000 600000 $ million 590000 580000 570000 560000 550000 year 2012 2017 2022 2027 — 0% reduction — 1% reduction — 5% reduction 31 CURRENT ECONOMIC COSTS OF OBESITY Health Care Costs n As a person’s BMI increases, so do the num- ber of sick days, medical claims and health n The medical cost of adult obesity in the care costs associated with that person.71 United States is difficult to calculate but esti- mates range from $147 billion to nearly $210 billion per year.61  The bulk of the spending is Higher Workers’ Compensation generated from treating obesity-related dis- Claims eases such as diabetes.62 n A number of studies have shown obese s Of the $147 billion, Medicare and Medicaid workers have higher workers’ compensation are responsible for $61.8 billion. Medicare claims.72, 73, 74, 75, 76, 77 and Medicaid spending would be 8.5 per- n Obese employees had $51,091 in medical cent and 11.8 percent lower, respectively, claims costs per 100 full-time employees, in the absence of obesity.63 compared with only $7,503 in medical claims s Obese people spend 42 percent more on costs for healthy-weight workers. And obese health care costs than healthy-weight people.64 workers had $59,178 in indemnity claims costs per 100 full-time employees, compared n Childhood obesity alone is responsible for with only $5,396 in indemnity claims costs for $14.1 billion in direct costs.65 healthy-weight employees.78 Indemnity claims n Annually, the average total health expenses are those where an insurer agrees to cover for a child treated for obesity under Medicaid the cost of losses suffered by the insured and is $6,730, while the average health cost for all can include medical payments and payment children covered by Medicaid is $2,446. The for lost time by the injured worker.   average total health expenses for a child treated for obesity under private insurance is $3,743, Occupational Health and Safety Costs while the average health cost for all children n Emergency responders and health care covered by private insurance is $1,108.66 providers face unique challenges in n ospitalizations of children and youths with a H transporting and treating the heaviest diagnosis of obesity nearly doubled between patients. According to one study, the number 1999 and 2005, while total costs for children of severely obese (BMI > 40) patients and youth with obesity-related hospitalizations quadrupled between 1986 and 2000 from one increased from $125.9 million in 2001 to $237.6 in 200 to one in 50. The number of super- million in 2005, measured in 2005 dollars.67 obese (BMI > 50) patients grew by a factor of five, from one in 2,000 to one in 400.79 n In California alone, the economic costs of overweight, obesity and physical inactivity are n A typical ambulance outfitted with equipment estimated at $41 billion a year.68 and two emergency medical technicians (EMTs) that can transport a 400-pound Decreased Worker Productivity and patient costs $70,000. A specially outfitted Increased Absenteeism bariatric ambulance that can transport patients weighing up to 1,000 pounds costs $110,000.80 n Obesity-related job absenteeism costs $4.3 billion annually.69 n A standard hospital bed can hold 500 pounds and costs $1,000. A bariatric n Obesity is associated with lower productivity hospital bed that can hold up to 1,000 while at work (presenteeism), which costs pounds costs $4,000.81 employers $506 per obese worker per year.70 32 B. FIVE TOP OBESITY-RELATED HEALTH ISSUES The NHF study commissioned by RWJF and problems related to obesity if trends continue TFAH examined the potential future rates — on their current track versus if average adult and related costs — of five of the leading health BMI was reduced by 5 percent in every state. 1. TYPE 2 DIABETES AND OBESITY Potential Diabetes Cases Avoided by 2030 if BMI is Reduced by 5 Percent (cases per 100,000 population) WA MT ND MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA n <2300 n >2300 & <2500 n >2500 & <2700 FL n >2700 & <2900 AK n >2900 & <3100 HI n >3100 Diabetes is the seventh leading cause of death in Being overweight or obese significantly in- the United States and accounts for $174 billion creases an individual’s risk of type 2 diabetes. in total U.S. health care costs.82 More than 80 percent of people with type 2 diabetes are overweight.90 Excess weight de- More than 25 million adult Americans have dia- creases the effectiveness of insulin, a hormone betes.83 Another 79 million Americans are pre- that transports sugar from blood to cells. When diabetic, which means they have elevated blood insulin doesn't work correctly, too much sugar sugar levels that can contribute to the develop- stays in the bloodstream. To make up for this, ment of diabetes.84 CDC projects that as many the cells that produce insulin must produce as one in three U.S. adults could have diabetes more of the hormone. This process may lead by 2050, and the analysis in this report shows the cells to deteriorate more quickly, exacerbat- the numbers could top 31 percent by 2030.85 ing the development of diabetes.91, 92 Over a 10-year period, the number of adults in People with type 2 diabetes have higher-than- the United States ages 18–79 with newly diag- normal levels of glucose, a source of sugar that nosed diabetes more than tripled from 493,000 humans produce by metabolizing carbohy- in 1980 to more than 1.7 million in 2010.86 drates, in their blood. High blood sugar con- About 1.9 million people aged 20 years or older tributes to a range of serious health problems, were newly diagnosed with diabetes in 2010.87 including heart disease, stroke, kidney disease, Approximately 215,000 individuals under the circulatory problems, neurological problems age of 20 have diabetes.88 Two million adoles- and eye damage. cents ages 12–19 have pre-diabetes.89 33 Nutrition, Physical Activity, Weight Loss and Diabetes The National Institute of Diabetes and Diges- percent, drug therapy reduced the incidence tive and Kidney Diseases (NIDDK) found that by only 31 percent.94 a 7 percent weight loss together with moderate Physical activity and weight loss both increase levels of physical activity (walking 30 minutes a insulin sensitivity, which increases the body’s day, five days a week) decreased the number of ability to transport sugar from the bloodstream new type 2 diabetes cases by 58 percent among to cells. A healthy diet, with recommended lev- people at risk for diabetes. 93 While the life- els of fruits, vegetables and grains and a limited style changes in nutrition and activity through amount of saturated fats and sweets, can also the Diabetes Prevention Program (DPP) re- help reduce the severity of the illness.95, 96, 97 duced the incidence of type 2 diabetes by 58 Diabetes Management and Teens: Study Finds Discouraging Results Because type 2 diabetes previously was consid- The research focused on nearly 700 overweight ered to be an adult condition, there are few stud- and obese teens recently diagnosed with type ies evaluating how to treat young people with the 2 diabetes. Teens were placed in one of three disease. New research in the New England Jour- treatment groups and followed for four years. nal of Medicine examined various treatments for One group took metformin, another took met- controlling blood sugar in teens. Results showed formin plus diet and exercise counseling, and the that nearly half of participants failed in controlling final group was given metformin plus a second the disease, and one in five suffered serious com- drug, Avandia. Results showed that half in the plications within a few years of diagnosis.98 The metformin group failed to maintain blood sugar results highlight the importance of preventing control, but the outcomes for the other two type 2 diabetes in the first place. groups were not much better.99 Where You Live Matters: Moving to Higher-Income Areas Reduces Risk of Obesity and Diabetes for Poor Women Between 1994 and 1998 the U.S. Department Medicine, revealed that having the option to move of Housing and Urban Development (HUD) to lower-poverty neighborhoods lowered the risk randomly assigned families living in public housing of obesity and diabetes among poor women.100 projects in high-poverty neighborhoods into an Women who were given the vouchers were experimental and control group. The experimen- almost one-fifth less likely to become extremely tal group was given vouchers to move to higher- obese and were one-fifth less likely to develop income neighborhoods, and the control group diabetes compared with women who were not did not receive vouchers. Findings of the study, offered the housing voucher.101 which were released in the New England Journal of 34 Diabetes Costs and Cases Potential Cases Potential Cost Potential Cases Potential Cost Savings 2010 New Diabetes Rank New Cases Avoided by 2020 Savings by 2020, New Diabetes Avoided by 2030, if by 2030, if Average State Number of Cases by 2030 by 2030 (per if Average BMI if Average BMI Cases by 2030 Average BMI Reduced BMI Reduced by 5% Cases (per 100,000) 100,000) Reduced by 5% Reduced by 5% by 5% (cumulative) (cumulative) (cumulative) (cumulative) Alabama 448,912 661,673 13,777 9 72,185 $1,152,000,000 141,297 $3,672,000,000 Alaska 50,843 69,728 9,648 49 7,892 $176,000,000 14,389 $546,000,000 Arizona 496,106 728,569 11,239 42 79,411 $1,739,000,000 154,737 $5,781,000,000 Arkansas 265,417 381,937 13,000 18 41,337 $722,000,000 80,530 $2,324,000,000 California 2,694,595 3,798,591 10,078 48 420,642 $9,747,000,000 796,430 $31,087,000,000 Colorado 333,206 519,150 10,146 47 54,596 $1,247,000,000 108,067 $4,043,000,000 Connecticut 267,944 412,641 11,524 37 42,682 $887,000,000 83,932 $2,824,000,000 Delaware 79,275 121,193 13,360 13 13,017 $228,000,000 25,427 $721,000,000 DC 40,312 57,758 9,346 50 6,155 $133,000,000 11,705 $433,000,000 Florida 1,722,611 2,442,415 12,816 19 260,135 $4,459,000,000 501,976 $14,074,000,000 Georgia 754,593 1,119,425 11,405 40 123,475 $2,563,000,000 238,019 $8,324,000,000 Hawaii 105,063 151,655 11,031 45 15,879 $319,000,000 31,634 $1,051,000,000 Idaho 119,270 176,821 11,156 43 19,384 $404,000,000 36,677 $1,274,000,000 Illinois 1,014,097 1,525,779 11,856 34 167,300 $3,434,000,000 325,721 $11,141,000,000 Indiana 544,815 814,420 12,497 25 89,021 $1,635,000,000 170,743 $5,160,000,000 Iowa 262,746 367,691 12,007 33 40,851 $726,000,000 77,783 $2,287,000,000 Kansas 239,691 367,777 12,809 20 39,537 $741,000,000 77,294 $2,390,000,000 Kentucky 394,029 594,058 13,596 10 63,793 $1,104,000,000 124,701 $3,503,000,000 Louisiana 398,422 605,617 13,238 14 66,884 $1,212,000,000 127,455 $3,882,000,000 Maine 120,878 192,680 14,507 3 19,949 $344,000,000 40,550 $1,114,000,000 Maryland 469,294 741,358 12,720 21 79,731 $1,580,000,000 158,413 $5,211,000,000 Massachusetts 483,855 745,248 11,313 41 77,206 $1,656,000,000 155,532 $5,436,000,000 Michigan 861,006 1,382,370 13,997 5 147,056 $2,777,000,000 294,113 $9,067,000,000 Minnesota 410,004 609,902 11,411 39 65,368 $1,350,000,000 127,368 $4,367,000,000 Mississippi 284,269 415,353 13,945 6 45,988 $774,000,000 86,347 $2,472,000,000 Missouri 535,793 843,420 14,032 4 90,942 $1,575,000,000 179,659 $5,084,000,000 Montana 83,849 126,162 12,639 22 13,156 $234,000,000 26,522 $758,000,000 Nebraska 152,276 225,263 12,225 30 24,784 $458,000,000 47,577 $1,456,000,000 Nevada 214,217 311,630 11,443 38 34,232 $690,000,000 65,087 $2,172,000,000 New Hampshire 108,764 182,570 13,850 8 18,692 $385,000,000 38,425 $1,239,000,000 New Jersey 607,689 971,386 11,012 46 103,119 $158,000,000 202,357 $520,000,000 New Mexico 173,054 252,907 12,146 31 26,569 $486,000,000 52,597 $1,599,000,000 New York 1,516,923 2,260,299 11,612 36 241,952 $4,774,000,000 473,588 $15,726,000,000 North Carolina 820,118 1,217,093 12,604 24 134,610 $2,363,000,000 261,785 $7,746,000,000 North Dakota 58,887 79,617 11,641 35 8,809 $150,000,000 16,873 $491,000,000 Ohio 1,012,377 1,599,091 13,851 7 174,329 $3,075,000,000 342,192 $9,899,000,000 Oklahoma 337,823 512,801 13,525 12 56,835 $912,000,000 110,522 $2,950,000,000 Oregon 313,737 467,643 12,078 32 49,676 $936,000,000 98,578 $3,089,000,000 Pennsylvania 1,135,646 1,731,248 13,586 11 185,919 $3,208,000,000 366,995 $10,318,000,000 Rhode Island 82,811 138,930 13,215 15 14,308 $297,000,000 29,889 $1,018,000,000 South Carolina 429,273 615,599 13,156 16 68,972 $1,099,000,000 133,498 $3,548,000,000 South Dakota 70,269 101,181 12,278 29 11,166 $196,000,000 21,780 $638,000,000 Tennessee 594,871 939,564 14,673 2 102,390 $1,676,000,000 201,257 $5,505,000,000 Texas 1,962,059 2,851,687 11,107 44 321,447 $6,597,000,000 605,152 $21,338,000,000 Utah 164,385 243,915 8,658 51 27,327 $718,000,000 50,992 $2,289,000,000 Vermont 50,472 77,189 12,322 28 8,000 $160,000,000 16,193 $526,000,000 Virginia 644,975 1,020,739 12,607 23 106,956 $2,122,000,000 209,621 $6,837,000,000 Washington 550,296 844,602 12,366 27 90,361 $1,680,000,000 178,401 $5,534,000,000 West Virginia 191,529 282,164 15,208 1 29,964 $430,000,000 59,669 $1,391,000,000 Wisconsin 470,136 708,716 12,408 26 74,310 $1,442,000,000 147,935 $4,733,000,000 Wyoming 48,566 73,889 13,005 17 7,750 $127,000,000 15,596 $421,000,000 35 2. HEART DISEASE, STROKE AND OBESITY Potential Chronic Heart Disease & Stroke Cases Avoided by 2030 if BMI is Reduced by 5 Percent (cases per 100,000 population) WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA n <2000 n <2000 & <2100 n >2100 & <2200 FL n >2200 & <2300 AK n >2300 & <2400 HI n >2400 & <2500 n >2500 Being overweight or obese raises the risk of having throughout the body, and especially in blood ves- high blood pressure, having high levels of harmful sels, may increase the risk of heart disease.102 blood fats known as triglycerides and high levels Most cardiovascular disease can be prevented or of low-density lipoprotein (LDL), also known as at least delayed until old age through a combina- “bad cholesterol.” And, it can lead to lower levels tion of direct medical care and community-based of high-density lipoprotein (HDL), also known as prevention programs and policies, particularly “good cholesterol.” These conditions can raise the those focusing on physical activity and nutrition, long-term risk of heart disease or stroke. Excess according to a review of more than 200 articles body fat can also produce chemicals in the body by the American Heart Association.103 that trigger inflammation. Chronic inflammation Weight Loss, Physical Activity, Nutrition and Heart Disease and Stroke For individuals who are overweight or obese, ev- terol, and reducing inflammation, which may idence indicates that losing as little as 5 percent decrease cardiovascular risk. It also reduces the to 10 percent of total weight can reduce the risk production of inflammatory chemicals in the of heart disease and stroke. For someone who body, and, as a result, reduces cardiovascular weighs 220 pounds, 5 percent of total weight is inflammation. In addition, exercise can help by 11 pounds. Weight loss may cut risks of heart strengthening the heart and improving blood disease and stroke by decreasing hypertension, flow. A healthy diet also can protect against lowering levels of triglycerides and bad choles- heart disease and stroke.104, 105 36 Coronary Heart Disease & Stroke Costs and Cases Potential Cases Potential Cost New CHD & Rank New CHD Potential Cost Savings Potential Cases 2010 New CHD & Avoided by 2020 Savings by 2030, Stroke Cases & Stroke Cases by 2020, if Average Avoided by 2030, if State Number of Stroke Cases if Average BMI if Average BMI by 2030 (per by 2030 (per BMI Reduced by 5% Average BMI Reduced Cases by 2030 Reduced by 5% Reduced by 5% 100,000) 100,000) (cumulative) by 5% (cumulative) (cumulative) (cumulative) Alabama 311,842 1,458,880 30,376 8 59,122 $1,627,000,000 121,749 $4,235,000,000 Alaska 29,747 150,217 20,785 50 6,273 $281,000,000 11,889 $692,000,000 Arizona 348,694 1,517,230 23,405 44 58,537 $2,148,000,000 114,546 $5,467,000,000 Arkansas 187,061 838,734 28,548 18 32,935 $1,027,000,000 67,867 $2,642,000,000 California 1,876,680 8,429,796 22,365 47 321,512 $13,923,000,000 656,970 $35,571,000,000 Colorado 231,944 1,175,789 22,979 46 45,232 $1,761,000,000 95,428 $4,735,000,000 Connecticut 214,986 1,014,057 28,320 20 37,776 $1,296,000,000 79,528 $3,316,000,000 Delaware 57,340 271,560 29,936 9 10,786 $344,000,000 22,261 $871,000,000 DC 29,219 131,194 21,229 49 4,721 $165,000,000 9,295 $406,000,000 Florida 1,412,354 6,188,174 32,471 3 234,408 $5,913,000,000 465,385 $14,684,000,000 Georgia 465,535 2,260,639 23,032 45 87,846 $3,735,000,000 185,409 $9,928,000,000 Hawaii 78,240 359,114 26,121 38 13,363 $482,000,000 26,286 $1,153,000,000 Idaho 85,114 377,940 23,845 42 15,232 $585,000,000 30,146 $1,454,000,000 Illinois 719,649 3,256,437 25,304 41 129,207 $4,649,000,000 268,967 $12,073,000,000 Indiana 386,193 1,746,600 26,801 32 72,338 $2,499,000,000 140,700 $5,922,000,000 Iowa 206,491 857,998 28,018 21 33,808 $940,000,000 67,065 $2,373,000,000 Kansas 176,438 769,578 26,803 31 31,727 $1,051,000,000 63,052 $2,560,000,000 Kentucky 264,958 1,278,342 29,257 14 52,389 $1,656,000,000 107,355 $4,298,000,000 Louisiana 274,399 1,222,533 26,723 34 50,964 $1,723,000,000 99,640 $4,120,000,000 Maine 91,512 462,648 34,833 2 17,970 $491,000,000 38,398 $1,265,000,000 Maryland 320,731 1,540,592 26,433 37 63,295 $2,408,000,000 129,330 $6,099,000,000 Massachusetts 375,028 1,792,732 27,214 27 65,085 $2,358,000,000 138,075 $5,918,000,000 Michigan 601,065 2,858,267 28,941 15 117,033 $4,401,000,000 241,967 $10,943,000,000 Minnesota 298,457 1,365,612 25,550 40 54,304 $2,071,000,000 111,066 $5,242,000,000 Mississippi 183,417 814,504 27,346 24 35,444 $1,122,000,000 66,897 $2,681,000,000 Missouri 383,542 1,760,591 29,291 13 73,330 $2,290,000,000 152,070 $5,935,000,000 Montana 64,244 304,870 30,542 6 12,018 $358,000,000 23,617 $847,000,000 Nebraska 116,013 491,469 26,672 35 20,435 $629,000,000 40,796 $1,593,000,000 Nevada 144,554 702,508 25,796 39 26,144 $989,000,000 55,556 $2,653,000,000 New Hampshire 76,996 407,757 30,933 5 16,082 $561,000,000 35,077 $1,467,000,000 New Jersey 398,981 2,087,173 23,661 43 77,009 $220,000,000 168,660 $610,000,000 New Mexico 123,330 559,598 26,875 29 21,384 $730,000,000 43,102 $1,782,000,000 New York 1,140,661 5,217,841 26,806 30 194,652 $6,777,000,000 410,326 $17,296,000,000 North Carolina 543,752 2,572,272 26,638 36 106,510 $3,733,000,000 213,310 $9,360,000,000 North Dakota 46,993 190,379 27,836 22 7,222 $183,000,000 14,116 $467,000,000 Ohio 732,181 3,398,949 29,441 12 145,120 $4,726,000,000 293,011 $11,718,000,000 Oklahoma 239,699 1,081,186 28,516 19 46,484 $1,345,000,000 92,323 $3,281,000,000 Oregon 225,575 1,054,888 27,245 26 40,229 $1,330,000,000 82,200 $3,388,000,000 Pennsylvania 892,129 3,964,312 31,110 4 150,111 $3,956,000,000 312,456 $9,867,000,000 Rhode Island 64,087 301,251 28,655 17 11,722 $394,000,000 25,063 $1,009,000,000 South Carolina 289,176 1,351,642 28,886 16 56,853 $1,682,000,000 114,735 $4,297,000,000 South Dakota 54,373 222,609 27,013 28 9,246 $277,000,000 17,899 $660,000,000 Tennessee 396,752 1,896,993 29,625 10 79,145 $2,380,000,000 162,325 $6,034,000,000 Texas 1,261,654 5,688,482 22,156 48 230,559 $9,169,000,000 465,739 $23,124,000,000 Utah 113,478 471,321 16,730 51 20,030 $1,026,000,000 37,723 $2,530,000,000 Vermont 38,031 190,617 30,429 7 6,978 $243,000,000 14,702 $618,000,000 Virginia 442,803 2,211,102 27,309 25 86,796 $3,041,000,000 183,631 $8,114,000,000 Washington 378,316 1,827,582 26,758 33 74,379 $2,575,000,000 151,285 $6,592,000,000 West Virginia 137,761 659,007 35,519 1 26,420 $685,000,000 53,768 $1,658,000,000 Wisconsin 347,847 1,579,761 27,658 23 59,574 $1,968,000,000 123,717 $5,171,000,000 Wyoming 35,021 167,970 29,564 11 6,619 $189,000,000 13,403 $474,000,000 37 3. HYPERTENSION AND OBESITY Potential Hypertension Cases Avoided by 2030 if BMI is Reduced by 5 Percent (cases per 100,000 population) WA MT ND MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD CA DC OK TN NC NM AR AZ SC MS AL GA TX LA n <1900 n >1900 & <2000 n >2000 & <2100 FL n >2100 & <2200 AK n >2200 & <2300 HI n >2300 Hypertension, often known as high blood pres- n ncreased activity of the sympathetic nervous I sure, can cause damage to an individual’s arter- system, which controls some automatic bodily ies, heart, brain, kidneys, eyes and other body functions, including blood pressure; functions and can increase an individual’s risk n ncreased salt retention and insulin resistance, I for heart disease, stroke, kidney damage and both of which can increase blood pressure; other health problems.106 About 1 in 3 U.S. adults—an estimated 68 million—have high n ncreased levels of systemic inflammation, I blood pressure.107 which can damage blood vessels and lead to hypertension; and Being overweight or obese can increase risk for hypertension in a number of ways: n ncreased risk of sleep apnea, which raises the I risk of high blood pressure.108 Nutrition, Physical Activity and Hypertension A range of studies have found that reducing a week and eating a healthy, lower sodium diet obesity can reduce high blood pressure. Losing also can help to lower high blood pressure. as little as five pounds can reduce hypertension Losing weight lowers blood pressure through a and may allow people to reduce the amount of combination of changes: reduced activity in the blood pressure medicine they take. Reducing sympathetic nervous system, reduced sodium sodium intake may also reduce the amount of intake, reduced systemic inflammation, and a blood pressure medicine needed. Getting at lowered risk of sleep apnea.109,110 least 30 minutes of physical activity several times 38 Hypertension Costs and Cases Potential Cases Potential Cost Potential Cases Potential Cost New Rank New 2010 New Avoided by 2020 Savings by 2020, Avoided by 2030, Savings by 2030, Hypertension Hypertension State Number of Hypertension if Average BMI if Average BMI if Average BMI if Average BMI Cases by 2030 Cases by 2030 Cases Cases by 2030 Reduced by 5% Reduced by 5% Reduced by 5% Reduced by 5% (per 100,000) (per 100,000) (cumulative) (cumulative) (cumulative) (cumulative) Alabama 1,006,222 1,286,270 26,782 10 60,370 $214,000,000 102,683 $570,000,000 Alaska 113,936 153,635 21,258 50 6,562 $36,000,000 10,826 $94,000,000 Arizona 1,176,899 1,449,229 22,356 47 67,742 $327,000,000 112,018 $876,000,000 Arkansas 606,605 749,537 25,512 26 34,933 $148,000,000 60,434 $391,000,000 California 6,478,109 8,427,912 22,360 46 364,104 $1,773,000,000 698,431 $5,422,000,000 Colorado 847,137 1,207,155 23,592 43 55,978 $274,000,000 97,935 $759,000,000 Connecticut 708,945 941,046 26,281 17 43,219 $184,000,000 75,911 $506,000,000 Delaware 187,986 245,280 27,039 8 11,575 $47,000,000 18,887 $119,000,000 DC 98,237 135,891 21,989 49 5,296 $26,000,000 9,665 $72,000,000 Florida 4,372,562 5,261,978 27,611 5 235,932 $827,000,000 401,924 $2,175,000,000 Georgia 1,649,642 2,285,570 23,286 44 106,004 $535,000,000 184,624 $1,492,000,000 Hawaii 264,816 332,347 24,174 42 14,587 $64,000,000 26,740 $184,000,000 Idaho 283,475 358,286 22,605 45 17,276 $77,000,000 29,084 $213,000,000 Illinois 2,369,745 3,142,673 24,420 38 145,937 $680,000,000 258,801 $1,889,000,000 Indiana 1,249,620 1,624,343 24,925 31 77,095 $334,000,000 128,579 $864,000,000 Iowa 636,409 765,455 24,996 29 34,573 $135,000,000 60,940 $369,000,000 Kansas 558,427 713,158 24,838 34 34,943 $144,000,000 57,769 $379,000,000 Kentucky 881,343 1,175,750 26,909 9 54,617 $219,000,000 93,198 $576,000,000 Louisiana 882,898 1,137,762 24,870 33 55,539 $241,000,000 91,451 $618,000,000 Maine 296,784 405,204 30,508 1 19,113 $73,000,000 33,364 $196,000,000 Maryland 1,083,304 1,488,428 25,538 25 71,397 $338,000,000 126,707 $930,000,000 Massachusetts 1,258,549 1,703,405 25,858 21 75,888 $340,000,000 135,308 $952,000,000 Michigan 1,934,745 2,612,251 26,450 15 122,761 $559,000,000 211,548 $1,480,000,000 Minnesota 990,242 1,312,110 24,549 36 60,985 $286,000,000 105,240 $783,000,000 Mississippi 595,822 751,568 25,233 28 35,861 $145,000,000 56,741 $357,000,000 Missouri 1,221,011 1,585,199 26,373 16 77,117 $295,000,000 133,798 $823,000,000 Montana 212,207 270,312 27,080 7 12,428 $49,000,000 21,391 $126,000,000 Nebraska 364,659 446,122 24,211 41 21,872 $91,000,000 36,005 $238,000,000 Nevada 511,848 663,428 24,361 39 31,999 $149,000,000 53,677 $401,000,000 New Hampshire 263,771 381,736 28,959 3 18,455 $83,000,000 31,320 $217,000,000 New Jersey 1,438,554 2,177,679 24,687 35 100,473 $37,000,000 177,570 $104,000,000 New Mexico 419,506 510,457 24,515 37 23,821 $95,000,000 40,458 $251,000,000 New York 3,749,386 4,953,893 25,450 27 219,567 $992,000,000 395,338 $2,793,000,000 North Carolina 1,831,530 2,413,521 24,994 30 113,366 $486,000,000 195,735 $1,311,000,000 North Dakota 145,630 170,470 24,925 31 7,667 $26,000,000 13,248 $75,000,000 Ohio 2,336,929 3,087,351 26,742 13 150,084 $621,000,000 249,255 $1,602,000,000 Oklahoma 765,126 969,830 25,579 23 46,939 $176,000,000 77,423 $451,000,000 Oregon 749,127 989,454 25,555 24 43,442 $182,000,000 77,631 $503,000,000 Pennsylvania 2,752,209 3,483,650 27,338 6 163,109 $609,000,000 284,931 $1,656,000,000 Rhode Island 207,285 281,265 26,754 12 12,973 $57,000,000 23,602 $155,000,000 South Carolina 961,722 1,216,272 25,993 18 56,291 $202,000,000 101,446 $568,000,000 South Dakota 169,415 200,392 24,317 40 9,724 $38,000,000 16,721 $103,000,000 Tennessee 1,299,689 1,714,690 26,778 11 83,372 $321,000,000 139,977 $842,000,000 Texas 4,300,252 5,689,509 22,160 48 271,638 $1,352,000,000 472,671 $3,777,000,000 Utah 390,890 501,184 17,790 51 24,341 $141,000,000 40,202 $393,000,000 Vermont 128,688 174,292 27,823 4 7,605 $34,000,000 13,976 $95,000,000 Virginia 1,512,608 2,103,174 25,976 19 96,997 $434,000,000 175,777 $1,219,000,000 Washington 1,282,066 1,760,032 25,769 22 83,258 $358,000,000 145,002 $987,000,000 West Virginia 433,914 558,316 30,092 2 25,474 $86,000,000 42,840 $220,000,000 Wisconsin 1,130,359 1,478,205 25,880 20 65,742 $286,000,000 114,692 $777,000,000 Wyoming 118,620 151,312 26,632 14 7,085 $23,000,000 12,119 $68,000,000 39 4. ARTHRITIS AND OBESITY Potential Arthritis Cases Avoided by 2030 if BMI is Reduced by 5 Percent (cases per 100,000 population) WA MT ND MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD CA DC OK TN NC NM AR AZ SC MS AL GA TX LA n <1000 n >1000 & <1100 n >1100 & <1200 FL n >1200 & <1300 AK n >1300 HI Obesity is a known risk factor for the develop- Being overweight or obese puts more stress on ment and progression of osteoarthritis of the joints and cartilage, and leads to increased de- knee and possibly of other joints. Obese adults terioration. Increased body fat also triggers the are up to four times more likely to develop osteo- production of inflammatory chemicals, which arthritis of the knee than healthy-weight adults.111 may accelerate the arthritic process.114, 115 Among individuals who have received a doc- Adults with arthritis are significantly less likely tor’s diagnosis of arthritis, 68.8 percent are to participate in leisure time physical activity overweight or obese.112 Obesity prevalence is compared with those without arthritis.116 54 percent higher among adults with arthritis compared with adults without arthritis.113 Arthritis and Weight Loss For those who are overweight or obese, losing production of inflammatory chemicals that can weight can make a significant difference for ar- worsen pain and speed deterioration.117, 118 thritis symptoms and for the overall progression For every pound of body weight lost, there is a of the disease. Losing as little as 5 percent of 4 percent reduction in knee joint stress among total body weight can reduce the pounding on overweight and obese people with osteoarthritis knees, hips and lower back, and can reduce the of the knee.119 40 Arthritis Costs and Cases Potential Cases Potential Cost Potential Cases Potential Cost Rank New New Arthritis Avoided by 2020 Savings by 2020, Avoided by 2030, Savings by 2030, 2010 Number of New Arthritis Arthritis Cases State Cases by 2030 if Average BMI if Average BMI if Average BMI if Average BMI Cases Cases by 2030 by 2030 (per (per 100,000) Reduced by 5% Reduced by 5% Reduced by 5% Reduced by 5% 100,000) (cumulative) (cumulative) (cumulative) (cumulative) Alabama 988,452 818,339 17,039 13 31,890 $295,000,000 59,554 $791,000,000 Alaska 117,391 104,801 14,501 50 3,845 $55,000,000 6,895 $151,000,000 Arizona 1,179,621 968,616 14,942 45 37,145 $436,000,000 68,326 $1,269,000,000 Arkansas 598,760 484,296 16,484 25 19,067 $193,000,000 36,343 $561,000,000 California 6,631,138 5,571,995 14,783 49 209,567 $2,758,000,000 387,850 $7,865,000,000 Colorado 875,842 786,503 15,371 44 29,984 $347,000,000 52,652 $949,000,000 Connecticut 710,198 597,155 16,677 20 20,911 $220,000,000 38,564 $608,000,000 Delaware 184,829 153,505 16,922 14 5,633 $54,000,000 10,341 $143,000,000 DC 103,440 92,032 14,892 47 3,424 $38,000,000 6,582 $118,000,000 Florida 4,225,438 3,266,082 17,138 9 117,776 $1,013,000,000 218,399 $2,849,000,000 Georgia 1,707,454 1,523,222 15,519 42 58,793 $752,000,000 108,753 $2,196,000,000 Hawaii 265,338 212,903 15,486 43 8,084 $84,000,000 14,834 $249,000,000 Idaho 285,313 236,068 14,894 46 8,828 $101,000,000 16,151 $286,000,000 Illinois 2,387,762 2,055,864 15,975 36 78,116 $923,000,000 149,927 $2,730,000,000 Indiana 1,243,233 1,054,503 16,181 31 40,079 $430,000,000 74,684 $1,200,000,000 Iowa 628,692 494,563 16,150 32 18,527 $176,000,000 34,635 $513,000,000 Kansas 555,211 460,030 16,022 35 17,199 $189,000,000 33,105 $515,000,000 Kentucky 876,143 748,558 17,132 10 29,187 $286,000,000 53,350 $790,000,000 Louisiana 877,591 744,189 16,267 30 29,645 $327,000,000 55,676 $915,000,000 Maine 290,329 248,703 18,725 1 9,457 $86,000,000 18,356 $249,000,000 Maryland 1,098,166 968,487 16,617 24 37,884 $458,000,000 70,406 $1,262,000,000 Massachusetts 1,270,472 1,096,100 16,639 22 40,777 $439,000,000 76,086 $1,257,000,000 Michigan 1,929,807 1,703,543 17,249 8 67,553 $771,000,000 126,613 $2,161,000,000 Minnesota 998,206 844,916 15,808 39 31,481 $365,000,000 56,923 $1,013,000,000 Mississippi 589,477 487,642 16,372 27 19,509 $191,000,000 35,176 $521,000,000 Missouri 1,207,427 1,016,888 16,918 15 40,031 $369,000,000 75,434 $1,082,000,000 Montana 207,585 170,323 17,063 11 6,418 $64,000,000 11,948 $175,000,000 Nebraska 361,250 290,050 15,741 41 11,093 $116,000,000 20,601 $321,000,000 Nevada 512,502 430,448 15,806 40 16,667 $191,000,000 30,746 $540,000,000 New Hampshire 262,518 239,199 18,146 3 8,806 $97,000,000 16,807 $265,000,000 New Jersey 1,504,360 1,418,265 16,078 34 48,075 $40,000,000 93,945 $119,000,000 New Mexico 413,967 332,573 15,972 37 13,701 $135,000,000 25,757 $391,000,000 New York 3,752,890 3,179,056 16,332 28 115,429 $1,347,000,000 220,151 $3,718,000,000 North Carolina 1,843,890 1,572,931 16,289 29 62,284 $679,000,000 115,491 $1,942,000,000 North Dakota 141,984 110,099 16,098 33 4,001 $39,000,000 7,585 $110,000,000 Ohio 2,316,148 1,969,338 17,058 12 75,273 $730,000,000 144,774 $2,131,000,000 Oklahoma 752,463 620,784 16,373 26 23,697 $233,000,000 44,816 $629,000,000 Oregon 751,876 645,284 16,666 21 24,122 $251,000,000 47,508 $754,000,000 Pennsylvania 2,691,043 2,214,204 17,376 7 84,103 $788,000,000 163,746 $2,267,000,000 Rhode Island 208,610 183,946 17,497 5 7,170 $79,000,000 13,856 $229,000,000 South Carolina 947,357 780,823 16,687 19 29,432 $278,000,000 58,678 $803,000,000 South Dakota 166,267 130,568 15,844 38 4,928 $52,000,000 9,625 $145,000,000 Tennessee 1,289,571 1,117,321 17,449 6 44,119 $428,000,000 84,332 $1,201,000,000 Texas 4,426,828 3,797,542 14,791 48 149,683 $1,704,000,000 270,868 $4,891,000,000 Utah 410,666 352,265 12,504 51 13,382 $190,000,000 23,918 $541,000,000 Vermont 127,660 110,302 17,608 4 4,228 $44,000,000 8,062 $129,000,000 Virginia 1,519,490 1,358,610 16,780 18 51,899 $579,000,000 104,689 $1,750,000,000 Washington 1,294,975 1,136,450 16,639 22 43,507 $477,000,000 82,370 $1,371,000,000 West Virginia 418,737 347,324 18,720 2 13,099 $111,000,000 25,307 $308,000,000 Wisconsin 1,124,133 958,720 16,785 17 34,499 $377,000,000 66,542 $1,091,000,000 Wyoming 116,541 95,973 16,892 16 3,744 $37,000,000 6,858 $100,000,000 41 5. CANCER AND OBESITY Potential Obesity-Related Cancer Cases Avoided by 2030 if BMI is Reduced by 5 Percent (cases per 100,000 population) WA ND MT MN VT ME SD WI OR ID NH WY MI NY IA MA NE PA RI IL IN OH CT NV UT NJ CO KS MO WV DE KY VA MD DC CA OK TN NC NM AR AZ SC MS AL GA TX LA n <150 n <150 & <175 n >175 & <200 FL n >200 & <225 AK n >225 & <250 HI n >250 & <275 n >275 Cancer death rates have declined in the United n pproximately 20 percent of cancer in A States in recent years, but the rise in obesity women and 15 percent of cancer in men is could change that trend. attributable to obesity.122 Being overweight, obese or physically inactive n ancer is the second-leading cause of death C can significantly increase a person’s risk of can- in the United States.123 cer. Approximately one-third of cancer deaths Research has found that obesity may increase the are linked to obesity or lack of physical activity, risk for many types of cancers through increased according to the American Cancer Society.120 A levels of some types of hormones (including es- review of 7,000 studies has shown links between trogen, insulin and other tumor growth regu- obesity and cancer.121 lators), chronic hypertension and/or damage caused by chronic low-level inflammation.124 Obesity Increases Risk for Some Types of Cancer Type of Cancer Estimated Percentage Cancer Cases Caused by Obesity Endometrial (lining of the uterus) 39 percent Esophageal 37 percent Kidney 25 percent Colon 11 percent Postmenopausal Breast 9 percent 42 Physical Activity and Cancer On the other hand, physical activity can reduce a There is also increasing evidence that limiting person’s risk for a variety of cancers, including:126 the amount of time a person spends sitting dur- ing the day, independent of physical activity, s olon cancer by 30 percent to 40 percent; C can also decrease the likelihood of developing s reast cancer by at least 20 percent; B obesity, type 2 diabetes, cardiovascular disease and some forms of cancer.128 s ndometrial (uterine) cancer by 20 percent E to 40 percent; and And, physical activity also has been shown to improve survival rates for individuals with colon s ung cancer by approximately 20 percent. L and breast cancer and slow the progression of Increased activity could prevent nearly 100,000 prostate cancer.129 cases of breast and colon cancer in the United States each year, according to one analysis of more than 200 current studies.127 Nutrition and Cancer According to the American Cancer Society or is lower in red and processed meats is as- Guidelines on Nutrition and Physical Activity sociated with lower risks of developing certain for Cancer Prevention, individuals who main- types of cancers.130 tain a healthy diet are at lower risk for cancer. Evidence also suggests that weight loss, through According to a review of the research, individ- calorie reduction with or without exercise, can uals who eat more processed and red meats, produce a significant reduction in various breast potatoes, refined grains and sugar-sweetened cancer biomarkers.131 Results from a recent beverages and foods are at a higher risk for de- study showed that weight loss of greater than 5 veloping some forms of cancer, while consum- percent could be associated with a 22 percent ing a diet that contains a variety of vegetables decrease in breast cancer risk. and fruits, whole grains and fish or poultry Breast Cancer and Weight Loss A randomized 12-month intervention published one of four study groups: diet, exercise, diet and in the Journal of Clinical Oncology reveals that exercise or control group. Results showed that biomarkers associated with postmenopausal women in the experimental groups experienced breast cancer can be improved through weight large and statistically significant reductions in sex loss, with or without exercise.132 The study hormones and an increase in sex-hormone bind- compared estrogen and androgen levels, which ing globulin (SHBG), which reduces bioactivity are both positively associated with risk for of the hormones.134 breast cancer,133 between women assigned to 43 Obesity Related Cancer Costs and Cases Potential Cases Potential Cost Potential Cases Rank New Potential Cost Savings New Cancer New Cancer Avoided by 2020 Savings by 2020, Avoided by 2030, 2010 Number Cancer Cases by 2030, if Average State Cases by Cases by 2030 if Average BMI if Average BMI if Average BMI of Cases by 2030 (per BMI Reduced by 5% 2030 (per 100,000) Reduced by 5% Reduced by 5% Reduced by 5% 100,000) (cumulative) (cumulative) (cumulative) (cumulative) Alabama 79,581 200,226 4,169 9 4,947 $95,000,000 9,846 $213,000,000 Alaska 7,892 21,927 3,034 50 434 $26,000,000 809 $51,000,000 Arizona 87,125 217,683 3,358 45 6,223 $123,000,000 9,983 $249,000,000 Arkansas 47,390 116,050 3,950 20 2,732 $76,000,000 5,347 $145,000,000 California 505,825 1,251,371 3,320 46 29,023 $689,000,000 52,769 $1,766,000,000 Colorado 64,932 176,171 3,443 43 3,684 $160,000,000 7,624 $313,000,000 Connecticut 58,115 147,883 4,130 12 2,900 $37,000,000 6,374 $118,000,000 Delaware 14,714 38,254 4,217 8 1,125 $23,000,000 1,923 $47,000,000 DC 8,417 20,320 3,288 48 371 $6,000,000 667 $7,000,000 Florida 352,183 869,214 4,561 3 24,965 $328,000,000 43,451 $656,000,000 Georgia 126,027 324,982 3,311 47 6,380 $382,000,000 12,073 $812,000,000 Hawaii 21,062 52,119 3,791 31 1,210 $27,000,000 2,323 $74,000,000 Idaho 21,778 53,889 3,400 44 1,474 $29,000,000 2,710 $51,000,000 Illinois 189,693 468,312 3,639 41 11,325 $163,000,000 23,036 $353,000,000 Indiana 99,188 243,537 3,737 33 6,387 $122,000,000 10,883 $256,000,000 Iowa 51,477 120,441 3,933 21 3,460 $84,000,000 5,849 $160,000,000 Kansas 44,590 106,322 3,703 38 2,527 $62,000,000 4,939 $132,000,000 Kentucky 68,075 176,260 4,034 16 4,151 $118,000,000 8,651 $277,000,000 Louisiana 69,400 170,092 3,718 36 3,934 $156,000,000 7,640 $302,000,000 Maine 23,721 65,041 4,897 1 1,886 $27,000,000 3,679 $53,000,000 Maryland 86,375 222,932 3,825 30 5,537 $156,000,000 10,841 $339,000,000 Massachusetts 102,436 266,466 4,045 15 6,851 $250,000,000 13,109 $489,000,000 Michigan 150,809 395,245 4,002 19 9,382 $203,000,000 18,370 $540,000,000 Minnesota 77,233 194,660 3,642 40 5,024 $118,000,000 8,338 $230,000,000 Mississippi 46,018 111,069 3,729 35 2,591 $34,000,000 4,795 $79,000,000 Missouri 96,772 241,389 4,016 18 6,852 $186,000,000 13,704 $438,000,000 Montana 16,490 42,793 4,287 7 868 $17,000,000 1,637 $46,000,000 Nebraska 29,132 68,288 3,706 37 1,935 $41,000,000 3,243 $79,000,000 Nevada 37,310 99,946 3,670 39 2,369 $82,000,000 4,521 $164,000,000 New Hampshire 20,353 57,513 4,363 5 1,318 $31,000,000 2,715 $65,000,000 New Jersey 110,882 308,035 3,492 42 6,616 $13,000,000 13,232 $31,000,000 New Mexico 32,920 80,166 3,850 28 1,978 $39,000,000 3,665 $72,000,000 New York 306,188 762,062 3,915 23 14,794 $206,000,000 29,392 $481,000,000 North Carolina 142,818 362,984 3,759 32 9,174 $371,000,000 17,382 $742,000,000 North Dakota 11,572 26,762 3,913 25 739 $19,000,000 1,272 $38,000,000 Ohio 185,989 470,919 4,079 13 12,469 $475,000,000 22,974 $977,000,000 Oklahoma 59,906 147,073 3,879 27 3,981 $83,000,000 7,128 $126,000,000 Oregon 58,349 151,854 3,922 22 3,678 $89,000,000 7,240 $200,000,000 Pennsylvania 227,588 553,041 4,340 6 15,674 $217,000,000 28,162 $393,000,000 Rhode Island 17,094 43,619 4,149 10 1,041 $29,000,000 2,092 $68,000,000 South Carolina 75,148 188,245 4,023 17 5,007 $52,000,000 9,124 $88,000,000 South Dakota 13,490 30,796 3,737 33 832 $8,000,000 1,467 $8,000,000 Tennessee 101,301 260,360 4,066 14 7,236 $124,000,000 14,151 $246,000,000 Texas 328,379 810,806 3,158 49 20,540 $560,000,000 34,918 $1,061,000,000 Utah 29,834 69,529 2,468 51 1,747 $47,000,000 2,845 $92,000,000 Vermont 10,273 27,751 4,430 4 614 $9,000,000 1,222 $12,000,000 Virginia 118,372 314,958 3,890 26 5,506 $89,000,000 13,764 $195,000,000 Washington 99,240 261,522 3,829 29 5,669 $107,000,000 11,748 $239,000,000 West Virginia 33,990 88,983 4,796 2 2,375 $33,000,000 4,379 $57,000,000 Wisconsin 89,046 223,559 3,914 24 4,341 $75,000,000 7,882 $187,000,000 Wyoming 9,068 23,573 4,149 10 574 $11,000,000 1,068 $21,000,000 44 C. ADDITIONAL HEALTH AND OBESITY ISSUES In addition to the five health issues examined in children and maternal health with a special focus the NHF analysis, obesity increases the risk for on breastfeeding, mental health and neurologi- a number of other health problems. Some key cal conditions with a special focus on dementia, areas reviewed in the following section include: kidney and liver diseases and HIV/AIDS. 1. Maternal Health and Obesity n There is a growing body of evidence document- healthy-weight counterparts to develop gesta- ing the links between maternal health condi- tional diabetes, a form of diabetes that arises tions, including obesity and chronic diseases, and during pregnancy and increases a woman’s risk increased risks before, during and after birth.135 of developing type 2 diabetes later on.138 n Children born to obese mothers are twice n CDC and the Kaiser Permanente Northwest as likely to be obese and to develop type 2 Center for Health Research found in a recent diabetes later in life.136 study that obesity during pregnancy is associ- ated with an increased use of health care ser- n Many pregnant women are overweight, obese, vices and longer hospital stays.139 The study of or have diabetes, all of which can have nega- more than 13,000 pregnancies found that obese tive effects on the fetus as well as the mother. women required more outpatient medications, According to CDC, approximately 50 percent were given more obstetrical ultrasounds, and of women of child-bearing age (between 18 were less likely to see nurse midwives or nurse and 44) were either overweight or obese in practitioners in favor of physicians. Cesarean 2002 and 9 percent had diabetes.137 delivery rates were 45.2 percent for extremely n Teenage mothers who are obese before preg- obese women, compared with 21.3 percent for nancy are four times more likely than their healthy-weight women.140 45 2. Breastfeeding and Obesity Prevention: For The Health Of The Child And The Mother Only Two States Meet States with the Highest Rates of Exclusive Breastfeeding Goals Breastfeeding at 6 Months Percentage Breastfeeding Children who are breastfed have lower rates Rank State Exclusively at 6 Months (2009) Obesity Ranking of obesity; this is especially true for those who 1 Colorado 26.6% 51 are breastfed exclusively, without formula 2 Oregon 26.3% 31 supplementation.141 Breastfeeding also is as- 3 Utah 24.8% 45 sociated with a range of other benefits, and 4 New Hampshire 24.7% 35 5 Vermont 23.3% 37 the American Academy of Pediatrics (AAP), 6 Idaho 23.2% 30 the American Academy of Family Physicians, 7 New Mexico 22.8% 34 the Academy of Breastfeeding Medicine, the 8 South Dakota 22.1% 23 World Health Organization, the United Na- 9 California 21.7% 46 tions Children’s Fund and many other health 10 Alaska 21.0% 28 organizations recommend exclusive breast- *Note: For rankings, 1 = Highest rate of breastfeeding. feeding for the first six months of life. States with the Lowest Rates of Exclusive However, according to CDC’s 2012 Breast- Breastfeeding at 6 Months feeding Report Card, only 16.3 percent of Percentage Breastfeeding Rank State Obesity Ranking mothers in the United States are breastfeed- Exclusively at 6 Months (2009) ing exclusively through six months, which is 51 Mississippi 7.6% 1 49 (tie) Alabama 9.1% 4 well below the Healthy People 2020 goal of 49 (tie) West Virginia 9.1% 3 25.5 percent.142 Only two states, Colorado 47 (tie) Kentucky 9.6% 10 and Oregon, meet this goal. 47 (tie) Louisiana 9.6% 2 46 Oklahoma 10.4% 6 45 Arkansas 10.6% 7 44 Ohio 11.0% 13 43 Nevada 11.7% 42 42 Montana 12.5% 41 *Note: For rankings, 51 = Lowest rate of breastfeeding. Evidence from a comprehensive review of existing breastfeeding A recent study at Children’s Hospital in Boston and Harvard Medi- research found that breastfeeding has the following effects:143 cal School found that feeding an infant solid food before 4 months of age may increase the baby’s risk of becoming obese as a tod- n For the child: reduced risk of ear, skin, stomach and respi- dler.148 The study included almost 900 infants; about two-thirds ratory infections, diarrhea, sudden infant death syndrome, were breastfed for at least four months.149 Follow-up at age 3 necrotizing enterocolitis, and other bacterial and viral in- revealed that 9 percent of the toddlers were obese.150 Results fections; and in the longer term, reduced risk of obesity, showed that among formula-fed babies, those that were intro- type 1 and 2 diabetes, asthma, celiac disease, inflammatory duced to solid foods before 4 months of age were six times more bowel disease and childhood leukemia.144 likely to be obese by age 3, but timing of solid food introduction n or the mother: quicker loss of pregnancy weight, prevention F was not associated with obesity among the breastfed babies.151 of postpartum bleeding and reduced risk of breast cancer, In conjunction with the release of the Let’s Move campaign in ovarian cancer, type 2 diabetes and postpartum depression.145 2010, the U.S. Breastfeeding Committee (USBC) released a The AAP recommends that babies are breastfed through the statement highlighting the importance of including breastfeeding first year of life.146 as part of the national strategy to reduce childhood obesity.152 Breast milk provides a baby with food that is nutritious and Data from the National Immunization Survey shows that approxi- easy for the baby to digest. It also gives the baby the ability to mately 75 percent of new mothers begin breastfeeding, but only decide when to eat and when to stop eating, allowing for the 43 percent are still breastfeeding at all at six months.153 According baby to develop healthy eating patterns. Keeping a baby at a to USBC chair, Dr. Joan Younger Meek, “The duration of breast- healthy weight from infancy is important because recent stud- feeding has been shown to be inversely related to overweight— ies have shown that overweight babies are more at risk for meaning that the longer the duration of breastfeeding, the lower being overweight or obese throughout childhood.147 the odds of overweight. And although further research is needed, exclusive breastfeeding appears to have a stronger protective ef- fect than breastfeeding combined with formula feeding.”154 46 Surgeon General’s Call to Action to Support Breastfeeding In an effort to make breastfeeding easier for n Provide education and training in breast- women, the U.S. Surgeon General has identi- feeding for all health professionals who care fied 20 key actions to improve support for for women and children. breastfeeding.155 n nclude basic support for breastfeeding as I Some key barriers to breastfeeding include:156 a standard of care for midwives, obstetri- cians, family physicians, nurse practitioners n ack of Knowledge L and pediatricians. n actation Problems L n Ensure access to services provided by Interna- n Poor Family and Social Support tional Board Certified Lactation Consultants. n Social Norms n dentify and address obstacles to greater I availability of safe banked donor milk for n Embarrassment fragile infants. n Employment and Child Care Employment n ealth Services H n Work toward establishing paid maternity In order to address some of the barriers to leave for all employed mothers. breastfeeding the Surgeon General suggests the n Ensure that employers establish and maintain following actions by various key stakeholders:157 comprehensive, high-quality lactation Mothers and Families support programs for their employees. n ive mothers the support they need to G n Expand the use of programs in the work- breastfeed. place that allow lactating mothers to have direct access to their babies. n evelop programs to educate fathers and D grandmothers about breastfeeding. n Ensure that all child care providers accom- modate the needs of breastfeeding mothers Communities and infants. n Strengthen programs that provide mother- to-mother support and peer counseling. Research and Surveillance n ncrease funding of high-quality research on I n Use community-based organizations to breastfeeding. support and promote breastfeeding. n Strengthen existing capacity and develop n Create a national campaign to promote future capacity for conducting research on breastfeeding. breastfeeding. n Ensure that the marketing of infant formula n evelop a national monitoring system to D is conducted in a way that minimizes its improve the tracking of breastfeeding rates negative impacts on exclusive breastfeeding. as well as the policies and environmental Health Care factors that affect breastfeeding. n Ensure that maternity care practices around Public Health Infrastructure the United States are fully supportive of n mprove national leadership on the promo- I breastfeeding. tion and support of breastfeeding. n evelop systems to guarantee continuity of D skilled support for lactation between hospitals and health care settings in the community. 47 3. Mental Health, Neurological Conditions and Obesity n Obesity may increase adults’ risk for demen- tion between depression and obesity. Obese tia. A review of 10 published studies found adults were more likely to have depression, that people who were obese at the beginning anxiety and other mental health conditions of the studies were 80 percent more likely to than healthy-weight adults.159 The odds of develop Alzheimer’s disease than those adults experiencing any mood disorder rose by 56 who had a normal weight at enrollment.158 percent among obese individuals (30 < BMI < 39.9) and doubled among the extremely n An analysis of data from a health survey of obese (BMI > 40).160 more than 40,000 Americans found a correla- Growing Evidence Suggests Link Between Obesity and Dementia During the past 10 years there has been between 60 and 70 years old. Researchers a growing body of research that suggests found that those with the highest BMIs and overweight and obesity are associated with largest waists scored the poorest on the reduced cognitive function, markers of brain cognitive tests.162 degeneration and increased risk of Alzheim- n In Neurology, researchers found that being er’s disease later in life. overweight or obese during middle age may Many of the studies linking obesity with de- increase the risk of dementia. The study mentia found that individuals with visceral included more than 8,500 twins from the fat, better known as belly fat, during midlife Swedish Twin Registry age 65 or older. were the most at risk. A few notable studies The participants were grouped according include the following: to their weight, which had been measured 30 years earlier. Results showed that those n n a 2008 National Institute of Aging funded I who were overweight or obese at middle study, researchers conducted a longitudinal life had an 80 percent higher risk of devel- analysis of more than 6,500 members of oping dementia, Alzheimer’s disease, or Kaiser Permanente of Northern Califor- vascular dementia in late life compared with nia who had their midsections measured the twins with normal BMIs.163 between 1964 and 1973. Diagnoses of de- mentia were found from medical records an A wide range of studies have found that physi- average of 36 years later. Results showed cal activity and maintaining a healthy weight that midsection obesity in midlife increases help limit a person’s risk for Alzheimer’s risk of dementia independent of diabetes and cognitive decline at any age.164 Accord- and other cardiovascular diseases.161 ing to Ronald Petersen, MD, director of the Alzheimer’s Research Center at the Mayo n Researchers in South Korea released find- Clinic: “Regular physical exercise is probably ings in 2012 of their study investigating the best means we have of preventing Al- the connection between visceral adipos- zheimer’s disease today, better than medica- ity, belly fat and risk of brain decline. The tions, better than intellectual activity, better study measured BMI and waist sizes and than supplements and diet.”165 tested cognitive abilities of 250 participants 48 Study: Stress and Obesity Studies have shown that low socioeconomic did not find a significant difference in weight, status and job stress, both of which are re- abdominal fat or cortisol awakening response lated to chronic stress, are associated with (CAR), which is a marker revealing stress abdominal obesity.166 levels, between the treatment and control groups, but it did find significant differences In an effort to more closely examine the among obese participants.167 Obese women relationship between stress and abdominal in the treatment group significantly reduced obesity, a recent randomized control study CAR and maintained body weight while looked at the effects of stress reduction in- women in the control group had stable CAR terventions on abdominal fat among a group and gained weight.168 of overweight or obese women. The study Sleep and Obesity A 2012 study released in the journal Sleep were getting less than seven hours of sleep provides additional evidence supporting the per night, genes played more than twice the connection between lack of sleep and obe- role in determining body weight than in those sity.169 In an effort to see the role genes play who were getting more than nine hours of in our weight, researchers measured BMI of sleep per night.170 Researchers were unable to more than 600 pairs of identical twins and determine why sleep has this effect on obesity examined how it varied based on sleep pat- genes, but suggest that less sleep may provide terns. They also examined almost 500 fraternal a more permissive environment for the expres- twins for comparison, since identical twins sion of obesity genes, or that more sleep may share all genes and fraternal share only some. be protective by suppressing obesity genes.171 Results showed that among participants who 4. Kidney Disease and Obesity n Obese individuals are 83 percent more likely n An estimated 24.2 percent of kidney disease to develop kidney disease than normal-weight cases among U.S. men and 33.9 percent of cases individuals, while overweight individuals are 40 among women are related to overweight and percent more likely to develop kidney disease.172 obesity.173 5. Liver Disease and Obesity n Obese individuals are at greater risk of nonalco- n NASH affects 2 percent to 5 percent of holic steatohepatitis (NASH), a liver disease that Americans. An additional 10 percent to 20 can lead to cirrhosis, in which the liver is per- percent have fat in their liver, but no inflam- manently damaged and scarred and no longer mation or liver damage, a condition called able to work properly. NASH ranks as one of “fatty liver.” Both types of liver disease have the major causes of cirrhosis in America, behind become more common as obesity rates have hepatitis C and alcoholic liver disease.174 risen in the country.175 49 6.HIV/AIDS and Obesity n Antiretroviral treatments are less effective for CD4 cell count after starting HIV treatment obese patients. One study found that obese than both patients of normal weight and those individuals had significantly smaller gains in who were overweight.176 WEIGHT BIAS AND QUALITY OF LIFE As obesity rates have gone up in the United States, Weight Bias in Health Care so, too, has the prevalence of weight discrimina- n More than 50 percent of primary care physicians tion. Researchers at the Yale University Rudd surveyed viewed obese patients as awkward, Center on Food Policy and Obesity report weight unattractive, ugly and noncompliant. One-third discrimination has increased by 66 percent over of the doctors surveyed described obese pa- the past decade in the United States and is now tients as weak-willed, sloppy and lazy.185 found at rates similar to racial discrimination.177,178 s Surveys of nurses,186 medical students,187 Weight bias and discrimination are found in all areas fitness professionals188 and dieticians189 re- of life, including the workplace, health care facilities, vealed similar biases. schools and universities, mass media and personal relationships. Stigmatization of obese individuals n A study investigating parents’ perceptions of threatens health, generates health disparities and words and descriptions used by health provid- interferes with obesity-intervention efforts.179 Re- ers explaining a child’s excess weight found searchers at the Rudd Center published a compre- that describing a child as “obese,” “extremely hensive review of articles on the stigma of obesity obese,” and “fat” were the most undesirable, in January 2009.180 A selection of documented find- stigmatizing, blaming and least motivating, ings on obesity bias and stigma are listed below. whereas “weight,” “unhealthy weight,” and “weight problem” were the most desirable and motivating descriptions.190 Weight Bias In Employment n In one survey of overweight and obese Weight Bias in Education women, 25 percent of participants said they experienced on-the-job discrimination be- n Teachers view overweight students as un- cause of their weight, 54 percent reported tidy, more emotional, less likely to succeed stigma from co-workers, and 43 percent ex- on homework and more likely to have family perienced stigma from their supervisors.181 problems.191 They also have lower expecta- tions for overweight students.192 n A 2007 study of more than 2,800 adults found that overweight adults were 12 times more likely to report weight-based employment Physical and Emotional Health discrimination, obese adults were 37 times Consequences of Weight Bias more likely, and severely obese adults were 100 times more likely.182 n Weight bias is associated with psychological consequences, including depression,193 lower n Compared with job applicants with the same levels of self-esteem194 and body image dis- qualifications, obese applicants are rated more satisfaction.195 negatively and are less likely to be hired.183 n Weight bias also is associated with unhealthy n Overweight people earn between 1 percent eating behaviors,196 physical activity levels197 and 6 percent less than non-overweight peo- and cardiovascular health outcomes.198 ple in comparable positions.184 50 Strategies And Policy Approaches To Improving Nutrition, Increasing Activity 3 Section And Reducing Obesity A ccording to CDC, more than half of Americans live with a chronic disease, many of which are related to obesity, poor nutrition and physical inactivity — and a majority of these diseases could be prevented.199 A wide range of evidence-based studies have working to implement promising approaches for found that effective disease prevention pro- improving health and reducing obesity. The follow- grams in schools, neighborhoods and work- ing section includes strategies and policy trends in places can reduce obesity rates, improve states, an overview of federal approaches toward obe- nutrition and increase physical activity. sity prevention in the past few years, and examples of prevention in action in communities, workplaces, As the evidence about what works continues to build, faith-based organizations and schools. many states and communities across the country are A. STATE OBESITY-RELATED LEGISLATION Since 2003, TFAH and RWJF have tracked state to tax policy, menu labeling, obesity liability obesity-related legislation relating to schools, in- and Complete Streets initiatives. This section cluding nutrition, physical education, physical provides an updated summary of legislation en- activity, and height and weight measurements. acted between June 1, 2011, and June 30, 2012. The report also has tracked legislation related 1. Legislation for Healthy Schools Studies show that school-based programs can in the cessation of funding for the following help prevent and reduce obesity.200 The more school year to the offending district.201 than 14,000 school districts in the country have Over the past decade, school-based efforts primary jurisdiction for setting local school poli- have focused on improving the quality of cies. States can set education policy or pass leg- food served and sold in cafeterias, vending islation, but school districts typically can decide machines and school stores, limiting sales of what policies they follow or implement, a prin- less nutritious foods and beverages, improving ciple known as local control. States often try physical and health education, and increasing to create incentives for districts to follow their physical activity. In addition, in the past few policies, such as attaching compliance rules to years, some districts have set up farm-to-school state funding. For example, if a school district programs that bring fresh, local produce into in New Mexico fails to meet the academic con- schools, encouraging both healthy eating and tent and performance standards for elementary sustainable farming. physical education programs, it would result 51 OBESITY-RELATED STANDARDS IN SCHOOLS – 2012 Nutritional Nutritional Limited Access Physical Physical Non-Invasive Health Standards for BMI or Health Farm-to-School States Standards for to Competitive Education Activity Screening for Education Competitive Info Collected Program School Meals Foods Requirement Requirement Diabetes Requirement Foods Alabama 3 3 3 3 3 3 Alaska 3 3 3 Arizona 3 3 3 3 3 3 Arkansas 3 3 3 3 3 3 California 3 3 3 3 3 3 3 3 Colorado 3 3 3 3 3 3 Connecticut 3 3 3 3 3 3 3 Delaware 3 3 3 3 DC 3 3 3 3 3 3 Florida 3 3 3 3 3 Georgia 3 3 3 Hawaii 3 3 3 3 Idaho 3 3 Illinois 3 3 3 3 3 3 3 3 Indiana 3 3 3 3 3 Iowa 3 3 3 3 3 Kansas 3 3 3 Kentucky 3 3 3 3 3 3 3 Louisiana 3 3 3 3 3 3 3 3 Maine 3 3 3 3 3 3 3 Maryland 3 3 3 3 3 Massachusetts 3 3 3 3 3 3 Michigan 3 3 3 Minnesota 3 3 Mississippi 3 3 3 3 3 Missouri 3 3 3 3 Montana 3 3 3 Nebraska 3 3 3 Nevada 3 3 3 3 3 3 New Hampshire 3 3 New Jersey 3 3 3 3 3 3 New Mexico 3 3 3 3 3 New York 3 3 3 3 3 North Carolina 3 3 3 3 3 3 3 North Dakota 3 3 3 Ohio 3 3 3 3 3 Oklahoma 3 3 3 3 3 3 Oregon 3 3 3 3 3 Pennsylvania 3 3 3 3 3 3 Rhode Island 3 3 3 3 South Carolina 3 3 3 3 3 3 South Dakota 3 3 3 Tennessee 3 3 3 3 3 3 3 Texas 3 3 3 3 3 3 3 Utah 3 3 3 Vermont 3 3 3 3 3 3 3 Virginia 3 3 3 3 Washington 3 3 3 3 West Virginia 3 3 3 3 3 Wisconsin 3 3 3 Wyoming 3 3 # of States 20 + D.C. 35 + D.C. 29 + D.C. 50 + D.C. 12 21 2 48 + D.C. 28 + D.C. Please Note: Checkmarks in chart above that are in red type represent new laws passed 2011 or 2012. 52 SCHOOL MEALS The foods and beverages available in schools supersede the state laws at that time, but states have a significant impact on children’s diets, con- will still be able to retain stronger standards if tributing more than 35 percent of many students’ they have those in place. daily caloric intake.202 In 2010, Congress passed The USDA is required to oversee the transi- the Healthy, Hunger-Free Kids Act, which in- tion to healthier school meals, and schools that cluded many provisions to improve student comply will be eligible for increased federal re- health. Most notable was the charge to USDA imbursements for school meals. to update nutrition standards for school meals and competitive foods. USDA released updated n Eight years ago, only four states had standards for the National School Lunch Pro- school meal standards that were stricter gram and School Breakfast Program earlier this than the old USDA requirements: Arkan- year, which will impact tens of millions of stu- sas, South Dakota, Tennessee and Texas. dents who participate in those programs. These n Today, 20 states and Washington, D.C. improvements, which are the first changes to have stricter standards than the old USDA national school meal standards in more than 15 requirements: Alabama, Arizona, Arkansas, years, will be phased in over a three-year period California, Colorado, Connecticut, Kentucky, beginning with the 2012-2013 school year with Louisiana, Massachusetts, Mississippi, Nevada, schools having the flexibility to focus on changes New Jersey, North Carolina, Oklahoma, Rhode to the lunch menu. Changes during the first year Island, South Carolina, South Dakota, Tennes- will include increased servings of fruits and vege- see, Texas, and Vermont. tables, increasing the amount of whole grains and phasing to only fat-free and low-fat milk at lunch. No state updated regulations regarding school The new national standards for school meals will meals between June 1, 2011, and June 30, 2012. 2012 NATIONAL SCHOOL MEAL STANDARDS Below is a comparison of current and new re- The current requirements will be replaced with quirements to the National School Lunch Pro- new national requirements, which are being gram (the final rule also includes requirements phased in over three years starting during the for school breakfast and nutrient standards 2012-2013 school year. States with standards not shown below). that are stronger than the new national stan- dards will be able to retain those standards. Food Group Current Requirements New Requirements Fruits and ½ - ¾ cup of fruit and vegetables ¾ - 1 cup of vegetables plus ½ - 1 cup of fruit per day Vegetables combined per day Vegetables No specifications as to type of Weekly requirements for: dark green, red/orange, vegetable subgroup beans/peas, starchy, others (as defined in 2010 Dietary Guidelines) Meat/Meat 1.5 – 2 ounce equivalent (daily Daily minimum and weekly ranges: Alternate minimum) (oz eq. min.) Grades K-5: 1 oz eq. min. daily (8-10 oz weekly) Grades 6-8: 1 oz eq. min. daily (9-10 oz weekly) Grades 9-12: 2 oz eq. min. daily (10-12 oz weekly) Grains 8 servings per week (minimum Daily minimum and weekly ranges: of 1 serving per day) Grades K-5: 1 oz eq. min. daily (8-9 oz weekly) Grades 6-8: 1 oz eq. min. daily (8-10 oz weekly) Grades 9-12: 2 oz eq. min. daily (10-12 oz weekly) Whole Grains Encouraged At least half of the grains must be whole grain-rich beginning July 1, 2012. Beginning July 1, 2014, all grains must be whole grain-rich. Milk 1 cup; Variety of fat contents 1 cup; Must be fat-free (unflavored/flavored) or 1% allowed; flavor not restricted low fat (unflavored) Source: Food and Nutrition Service, USDA. Ounce equivalent (oz eq.) means the having the same nutri- tional value as in a standard ounce of that food group. http://www.fns.usda.gov/cnd/Governance/Legisla- tion/comparison.pdf (accessed March 6, 2012). 53 Increasing Fruit and Vegetable Consumption at School through Salad Bars In an effort to increase the amount of fruits provided on salad bars.203 But few schools take and vegetables consumed by children, the advantage of salad bars, whether for lack of Food Family Farming Foundation, National knowledge or due to financial constraints. In Fruit and Vegetable Alliance, United Fresh order to increase children’s access to salad Produce Association Foundation, and Whole bars at schools, any school that participates Foods Market put forth the initiative Let’s in the National School Lunch Program can Move Salad Bars to Schools to support First apply for a grant that helps to pay for salad Lady Michelle Obama’s Let’s Move! initiative. bar equipment. The Let’s Move Salad Bars to Schools program hopes to fund and award Evidence shows that children consume more 6,000 salad bars by the end of 2013.204 fruits and vegetables, and try new foods, when they have a variety of choices like those GOT WATER? Research shows that children are not drinking consumption and improve health. The Healthy, enough water during the school day.205 Al- Hunger-Free Kids Act of 2010 requires schools though water fountains have been available in to provide easily accessible, clean water to most schools for decades, there are issues that students at no cost. However, some advocates discourage students from drinking water at worry that the law is too vague about how school. For example, many schools do not have schools should actually accomplish this. In enough water fountains to supply all of the stu- an effort to help schools improve quality of dents, and most schools do not make cups avail- and access to water in schools Change Lab able to encourage students to take more water Solutions has a range of resources and policy from the fountains. The cost of providing cups ideas to improve drinking water at schools. may be a barrier in some schools.206 More information can be found at: http:// changelabsolutions.org/publications/water- In addition, encouraging students to drink free access-schools-model-wellness-policy-language. water decreases revenue from bottled water sales, which often fund extracurricular activi- n oday two states have water T ties.207 Issues with water quality, such as com- regulations that make clean water plaints about taste or excessive lead content, accessible to students throughout also prevent students in some districts from the school day at no cost to students: drinking water at school. Massachusetts and West Virginia. But evidence shows that making water more No state implemented new regulations on water in available to students can increase water schools between June 1, 2011, and June 30, 2012. Give Them Water and They Will Drink It A recent study published in Preventing Chronic cation.212 Researchers measured consumption Disease found that students will drink more of water before the program and at one week water if it is made available to them.211 A middle and two months after the completion of the school in Los Angeles conducted a five-week program at both the intervention school and a program that included providing cold, filtered comparison school.213 Students at the interven- drinking water in cafeterias; distributing reusable tion school had higher adjusted odds of drinking water bottles to students and staff; conducting water from fountains and reusable water bottles school promotional activities; and providing edu- than the comparison school.214 54 COMPETITIVE FOODS The USDA defines competitive foods as any States that implemented new regulations re- food or beverage served or sold at school that is garding competitive foods between June 1, not part of the USDA school meals program.215 2011, and June 30, 2012: These foods are sold in à la carte lines, in school n olorado prohibited the availability of any C vending machines, in school stores, or through food or beverage that contains any amount of bake sales. In 2012, USDA is expected to pub- industrially produced trans fat or the use of lish a proposed rule updating nutrition standards food that contains any industrially produced for “competitive foods.” trans fat in the preparation of food or bever- The current standards for competitive foods are ages for students (SB 12-068, 2012). more than 30 years old, and the federal govern- n elaware banned the sale of any food or D ment does not regulate products beyond those beverage containing industrially produced classified as foods of minimal nutritional value trans fat to students in grades K-12 during (FMNV).216 FMNV are identified by the school the normal or extended school day on school meals program as carbonated beverages, water grounds (HB 3, 2011). ices, chewing gum, hard candy, jellies and gums, marshmallow candies, fondant, licorice, spun Start time and place standards for competitive candy, and candy-coated popcorn.217 As such, foods include: many competitive foods are high in calories, fat, n ight years ago, 17 states had laws E sugar and sodium. Schools commonly sell sugary about when and where competitive drinks, salty snacks, pizza, ice cream and french foods can be sold that were stricter than fries, often from multiple venues. Forty percent federal requirements: Arkansas, California, of students purchase these snacks on a daily basis, Colorado, Connecticut, Florida, Georgia, and, as of the 2009-2010 school year, almost half Hawaii, Illinois, Kentucky, Louisiana, Maine, of elementary school students could purchase un- Mississippi, Nebraska, New York, North healthy competitive foods at school.218 Carolina, Texas and West Virginia. n Eight years ago only six states had nutri- n oday, 29 states and Washington, D.C., T tional standards for competitive foods: have laws that limit when and where Arkansas, California, Hawaii, Tennessee, competitive foods may be sold that Texas and West Virginia. exceed federal requirements: Alabama, n oday, 35 states and Washington, D.C. T Arizona, Arkansas, California, Colorado, have nutritional standards for competitive Connecticut, Florida, Georgia, Hawaii, Illinois, foods: Alabama, Arizona, Arkansas, California, Indiana, Kentucky, Louisiana, Maine, Maryland, Colorado, Connecticut, Delaware, Hawaii, Mississippi, Nebraska, Nevada, New Jersey, Illinois, Indiana, Iowa, Kansas, Kentucky, New Mexico, New York, North Carolina, Louisiana, Maine, Maryland, Massachusetts, Oklahoma, Oregon, Pennsylvania, South Mississippi, Nevada, New Jersey, New Mexico, Carolina, Texas, Vermont and West Virginia. North Carolina, Ohio, Oklahoma, Oregon, No state implemented new regulations regarding Pennsylvania, Rhode Island, South Carolina, competitive foods between June 1, 2011, and Tennessee, Texas, Utah, Vermont, Virginia, June 30, 2012. Washington and West Virginia. Strong Support for USDA Competitive Food Standards Recent polling commissioned by the Kids’ Safe & unhealthy snacks at school, more than 80 per- Healthful Foods Project, a joint project between cent are concerned about childhood obesity, The Pew Charitable Trusts and RWJF, found 83 percent believe foods sold through vending strong public support for national standards to machines are not really healthy or nutritious, limit calories, fat and sodium in snack and à la and 68 percent said food purchased from à carte foods sold to students at schools.219 la carte lines and school stores is not really healthy or nutritious.220 Results from the poll show that 80 percent of American voters favor national standards for 55 Student Health and School Budgets Could Benefit from Updating Nutrition Standards for Competitive Foods The Kids’ Safe & Healthful Foods Project and the n Vulnerable populations would benefit be- Health Impact Project, funded by The Pew Char- cause students from lower-income families itable Trusts and RWJF, worked with Upstream who participate in free and reduced-price Public Health to conduct a health impact assess- meal programs would be more likely to buy ment (HIA) of the possible effects of updating healthier foods. competitive food policies. The HIA assumes that Based on findings of the HIA, the Kids’ Safe & new guidelines would be required to meet the Healthful Foods and Health Impact projects 2010 Dietary Guidelines for Americans (DGA). recommend that the USDA:222 Results of the HIA find that if school competitive food policies adhered to the 2010 DGA:221 n Establish nutrition standards for all foods that are regularly sold onsite during the n Student access to, purchase of, and con- school day but that are outside of the sumption of unhealthy foods and beverages, USDA meals program; and subsequently their risk for disease, would decrease; n Set nutrition guidelines for all beverages sold on school grounds; and n Districts would likely not see a decline in revenue because children will purchase n Adopt policies and practices that ensure school meals if there are fewer items com- effective implementation of the standards. peting for their lunch money; and 56 THE FARM-TO-SCHOOL MOVEMENT GROWS Over the last decade, many cities and towns have developed farm- schools in the state. Six years ago only New York had a to-school programs, which bring local, fresh fruits and vegetables law that established a farm-to-school program. to school cafeterias. Often, the programs include farm visits, cook- States that implemented new farm-to-school legislation be- ing demonstrations, and the creation of school gardens and com- tween June 1, 2011, and June 30, 2012: posting sites. Some states have laws supporting the practice. n Alabama established the Farm to School Procurement Act, Studies show that these programs improve students’ diets.223 which mandates a coordination effort between the Depart- For example, a study by researchers at the University of ment of Education, the Department of Agriculture and In- California at Davis found that farm-to-school programs not dustries to provide local grown food to schools only increase consumption of fruits and vegetables, but (HB 670, 2012). actually change eating habits, causing students to choose healthier options at lunch.224 A recent health impact n Maine passed a law requiring that the Department of Agri- assessment conducted before the Oregon Farm to School culture, Food and Rural Resources, the Department of Edu- reimbursement law passed found that the law would cation and the Department of Marine Resources support create and maintain jobs for Oregonians, increase student a pilot program to examine the benefits of promoting the participation in school meal programs, improve household purchasing of food grown or raised and fish raised or caught food security and strengthen connections within Oregon’s by Maine food producers for use in primary and secondary food economy.225 school meal programs (LD 1446, 2011). These programs also increase the use of locally grown foods, n Missouri created the “Farm-to-Table Advisory Board” to and teach kids about local food and farming issues. put forth recommendations to help schools incorporate locally grown agricultural products into their cafeteria offer- n Twenty-eight states and Washington, D.C. currently ings, salad bars and vending machines, and increase public have established farm-to-school programs: Alabama, awareness of local agricultural practices and the role that Alaska, California, Colorado, Connecticut, Florida, Illinois, local agriculture plays in sustaining healthy communities and Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, supporting healthy lifestyles (HB 344, 2011). Michigan, Missouri, Montana, New Jersey, New Mexico, New York, Oklahoma, Oregon, Pennsylvania, Tennes- n New York passed legislation that finances the transpor- see, Texas, Vermont, Virginia, Washington and Wisconsin. tation and distribution of New York state farm grown Many of these programs cover portions of the students or products to schools, especially in underserved urban com- schools in these states rather than all of the students or munities (SB 614, 2011). Farm-to-School Stories Below are a few examples of what some schools and school dis- vegetables thanks to the farm-to-school program, which is in tricts are doing to increase access to fresh fruits and vegetables: its third year. In an effort to generate more interest in garden- ing, the farm-to-school project coordinator is hosting two Minnesota—In Minnesota, a new documentary, “Farm-to-School: workshops; the first is Green Teen Garden Workshop, which Growing Our Future,” is being aired on public television as well as is free to students, and the second is an annual workshop at several events around the state. The purpose of the documen- called Teaching in the Garden, which is free to local educators. tary is to help give momentum to the farm-to-school movement. The Teaching workshop aims to help educators establish farm- Among many vignettes, the video shows students helping harvest, to-school curriculum for the classroom.227 weigh and eventually eat beets from their school garden. The cre- ators of the documentary hope the video will be used as a resource California—In San Diego, school buses now have more than for the future as each DVD comes with detailed instructions on one purpose: a “farms on wheels” program will use some holding a community screening, talking about the documentary and buses as hands-on labs for students to learn more about moving forward with ideas for farm-to-school programs.226 agriculture and nutrition to complement the District’s current farm-to-school program.228 Indiana—At Batesville Primary School and High School, stu- dents have the opportunity to plant, grow and consume local 57 PHYSICAL EDUCATION, PHYSICAL ACTIVITY, AND HEALTH EDUCATION IN SCHOOLS The 2008 HHS Physical Activity Guidelines for high school students who were physically active Americans recommend that children engage in one at least an hour on all seven days in the previous hour or more of moderate or vigorous aerobic week ranged from 33.1 percent in Oklahoma to physical activity a day, including vigorous physical 20.8 percent in Utah.230 activity at least three days a week. Examples of In recent years, many school systems have elimi- moderate intensity aerobic activities include hiking, nated or cut PE. Generally, schools sacrifice skateboarding, bicycle riding and brisk walking. PE to give students more time to prepare for Vigorous-intensity aerobic activities include standardized tests, which are often required by bicycle riding, jumping rope, running, soccer, districts and states. basketball, and ice or field hockey. According to the Guidelines, children and adolescents also Physical Education should incorporate muscle-strengthening activities, such as rope climbing, sit-ups and tug-of war, three n very state has some physical education E days a week.  Finally, bone-strengthening activities, requirements for students. However, such as jumping rope, running and skipping, are these requirements are often limited or recommended three days a week. not enforced, and many programs are inadequate. A recent Bridging the Gap report found that many districts have made minor improvements States that implemented new laws between June to their wellness policies, but that physical edu- 1, 2011, and June 30, 2012: cation has been almost entirely taken out of the n irginia required that the Board of Education V standard curriculum for high schools and physi- develop physical education program guidelines cal activity is very low throughout all schools.229 for public elementary and middle schools prior Some key findings included: to January 1, 2014 (HB 1092, 2012). n In 2010, 83 percent of middle school students and 34 percent of high school students were Physical Activity required to take physical education during the n Many states have started enacting laws school year, but it is likely that half of the high requiring schools to provide a certain number school students only took physical education of minutes and/or a specified difficulty level for one semester or trimester. of physical activity. Twelve states require n Only 23 percent of middle school students and schools to provide physical activity or recess 13 percent of high school students walked or during the school day. bicycled to school in 2010. States that implemented new laws between June n Only 12 percent to 13 percent of high school 1, 2011, and June 30, 2012: students and 19 percent to 23 percent of mid- n onnecticut required each school under its C dle school students participated in intramural jurisdiction to include in the regular school sports and physical activity clubs in 2010. The day students enrolled in grades kindergarten rates were lower for girls than boys. through five, time devoted to physical activity According to data from the 2011 Youth Risk of at least twenty minutes daily (SB 458, 2012). Behavior Surveillance System, the percentage of 58 Physical Activity Breaks Physical activity breaks are a proven way to increase physical school students. Many states have started doing this, and fol- activity among students as well as enhance academic achieve- lowing enactment of a law in Texas requiring students to en- ment.231 Researchers found that third and fourth graders who gage in 30 minutes of daily physical activity studies show that participated in a physical activity break program took almost students across the state participated in around 30 percent 1,000 more steps during the school day than those not en- more physical activity than the minimum requirement.234 rolled in the program.232 Studies have also shown that these Schools are using a variety of tactics to reach the recom- short active breaks during the day improve elementary school mended 30 minutes of physical activity per day for students. students’ ability to stay on task during academic work by 20 Physical activity breaks often happen in the classroom and percent compared to no effect for inactive classroom breaks.233 consist of activities such as stretching, yoga or jumping jacks.235 Implementing state policies requiring physical activity breaks And, many schools use specific physical activity break programs is one way to increase the amount of daily physical activity for such as Brain Gym®, Take 10!® and the JAMmin’ Minute®.236 Health Education Health education curricula often include community health, information regarding diabetes, and new requirements for consumer health, environmental health, family life, mental and reporting to the Department of Education (HB 9, 2012). emotional health, injury prevention and safety, nutrition, per- According to the 2006 CDC study, health education standards sonal health, prevention and control of disease and substance and curricula vary greatly from school to school.238 use and abuse. The goal of school health education is to pre- vent premature deaths and disabilities by improving the health n The percentage of states that require districts or schools literacy of students.237 to follow national or state health education standards in- creased from 60.8 percent in 2000 to almost 75 percent in n Only two states — Colorado and Oklahoma — do not 2006; the percentage of districts that required this of their require schools to provide health education. schools increased from 68.8 percent to 79.3 percent. States that implemented new health education rules between n Almost 14 percent of states and 42.6 percent of districts June 1, 2011, and June 30, 2012: required each school to have a school health education n Maryland integrated new requirements into the health coordinator. curriculum, including the importance of physical activity and PHYSICAL ACTIVITY AND ACADEMIC ACHIEVEMENT Experts agree that physical activity improves children’s who were more physically fit scored better on a series health. However, most children still do not get enough of cognitive tests than those who were less fit.240 Brain physical activity. HHS Physical Activity Guidelines for scans showed that in the fitter kids, a key cognitive area Americans recommend children and adolescents engage in of the brain had greater volume. The researchers con- 60 minutes or more of physical activity each day. cluded that being fit enhanced the “executive control” portion of the children’s brains.241 In 2010, CDC issued Association Between School-based Physi- cal Activity, Including Physical Education, and Academic Perfor- n Children who perform better on physical capacity tests mance, a literature review which examined 23 years of research are more likely to receive higher reading and math and 50 studies about the relationship between school-based scores, even when the added time for physical activity physical activity, including physical education, and academic takes away from time in the classroom.242 performance.239 The majority of the studies found that physical n ntensive physical education programs in school can im- I activity was positively related to academic performance and that prove cognitive skills and attitudes, including concentra- adding time during the school day for physical activity does not tion, attention and classroom behavior.243 appear to take away from academic performance. n esearchers analyzed FITNESSGRAM® test results from R Other major findings include: more than 2.4 million Texas students in grades 3 to 12 dur- n Studies show that physical activity can actually improve ing the 2007-2008 school year, and found significant school- children’s brain function. For example, researchers at the level correlations between physical fitness achievement and University of Illinois found that nine- and ten-year-olds better performance on state standardized tests.244 59 BMI SCREENING AND SURVEILLANCE As of June 30, 2012, 22 states had legislation that n oday, 21 states have legislation that T mandates school-based BMI or other weight- requires BMI screening or weight-related related screenings in schools. Such assessments assessments other than BMI. are intended to help schools and communities s tates with BMI screening requirements: S assess rates of childhood obesity, educate par- Arkansas, California*, Florida, Illinois, Maine, ents and students, and serve as a means to eval- Missouri, New York, North Carolina, uate obesity prevention and control programs Ohio, Oklahoma, Pennsylvania, Tennessee, in that school and community. The American Vermont and West Virginia. Academy of Pediatrics (AAP) recommends that BMI should be calculated and plotted annually s tates with other weight-related S for all youth as part of normal health supervi- screening requirements: Delaware, Iowa, sion within the child’s medical home, and the Louisiana, Massachusetts, Nevada, South Institute of Medicine (IOM) recommends annual Carolina and Texas. school-based BMI screenings.245, 246 *Starting July 2010, statewide distribution of n ight years ago, only four states required E diabetes risk information to schoolchildren, BMI screening or other weight-related California Education Code § 49452.7, replaced assessments for children and adolescents: individual BMI reporting, California Education Arkansas, Kansas, Louisiana and Massachusetts. Code § 49452.6. Childhood Obesity Rates in New York City Decrease In 2005, the New York City Department of Ed- drop, of 3.2 percent, was observed among 11 ucation started annually measuring BMI of public to 14-year-olds.248 Obesity rates among White school students in grades K-12 during physical and Asian/Pacific Islander children decreased by education classes. Results from this data collec- 12.5 percent and 7.6 percent respectively.249 tion show that obesity decreased among 5-14 Although obesity rates also dropped signifi- year olds by 5.5 percent—from 21.9 percent in cantly among Black and Hispanic children, by 2006-2007 to 20.7 percent in 2010-2011.247 1.9 percent and 3.4 percent respectively, these declines were smaller than those observed Obesity rates decreased significantly among all among other races/ethnicities.250 Children age groups, racial/ethnic groups and neighbor- coming from low poverty neighborhoods had hood poverty levels, but some groups saw the greatest decrease in obesity rates of 7.8 more significant improvements than others. percent compared with those coming from The obesity rate among 5 to 6-year-olds de- very high poverty neighborhoods that experi- clined by almost 10 percent, which was the enced a decrease by 2.9 percent.251 largest drop for any age group. The smallest 60 Using Child Care Quality Rating and Improvement Systems (QRISs) to Prevent Childhood Obesity Child care facilities can have a major impact on childhood obe- many challenges states face in incorporating new standards, sity prevention. Second only to the home, child care settings including:256 are where young children spend their time. More than three- n ack of staff training and capacity—staff that currently L fifths of children under age 5 are in some type of regular child provide support to child care facilities lack training and ex- care arrangement.252 pertise in the topics of nutrition, physical activity and screen Recently, states have been incorporating nutrition, physical ac- time. The same is true for the raters who assess the quality tivity and screen time standards into child care Quality Rating of child care facilities. Training would be necessary to bring and Improvement Systems (QRISs).253 QRISs are a voluntary them up to speed with the new standards. approach to improving the quality of early care and educa- n Increased implementation and monitoring costs— tion programs, and are designed to incentivize improvement both child care providers and QRIS programs see including through voluntary, market-driven actions.254 Most states cur- health standards as an increased cost and that they do not rently use QRISs to improve the quality and education of child have adequate funding to meet the standards. care facilities, but their use has been emerging as a new strat- egy to improve the quality of health as well.255 n Absence of tools and methods to monitor providers’ achievements of standards—existing tools used to rate Altarum Institute recently put together a report, State Efforts child care facilities are not set up to assess the new stan- to Address Obesity Prevention In Child Care Quality Rating dards of nutrition, physical activity and screen time. and Improvement Systems, evaluating the current state of obesity prevention as part of QRISs. The report found many n takeholder resistance—states have experienced S states are making progress in including nutrition, physical pushback from several stakeholders, including parents and activity and screen time standards into QRISs, yet there are faith-based entities providing care. Review: Obesity Prevention Interventions Can Help Children Be Healthier A review evaluating the effectiveness of obesity prevention n Support for teachers and other staff to implement health interventions among children found strong evidence show- promotion strategies and activities, such as professional ing that the programs helped children make progress to- development and capacity building activities; and ward achieving a healthier body weight. The study included n Encourage parents and other care providers to support a review of 55 controlled studies targeting children age 6 children to be more active, eat more nutritious foods and to 12 through policies or programs in place for at least 12 spend less time in screen-based activities at home. weeks. According to the review, the following were cited as the most promising policies and strategies:257 The review also found that obesity prevention interventions aimed at promoting a healthy weight among children were n School curriculum that includes focus on healthy eating, not associated with increased body image issues, unhealthy physical activity and healthy body image; eating or dieting practices, or harmful attitudes about n ncreased sessions for physical activity and the development of I weight.258 But, the authors note that while they found fundamental movement skills throughout the school week; strong evidence supporting the programs, the findings must be interpreted cautiously due to heterogeneity and the n mprovements to nutritional quality of the food supply in I potential for small study bias in the interventions.259 The schools; study highlights the importance of continued investment n Providing an environment and culture that support the into more obesity prevention studies focused on children, ability of children to make healthier choices and be more as well as detailed follow up of interventions to see what physically active throughout the entire day; works, for whom and at what cost. 61 Childhood Obesity: Reaching Healthy People Goals Through Energy Reduction Healthy People 2010 and Healthy People 2020 2020 goals by 2020, non-Hispanic black 2-19 both have goals for reducing childhood obesity. year olds would need to reduce daily intake by A recent study from the American Journal of Pre- 138 calories, Mexican-Americans by 91 calories ventive Medicine reveals exactly how many fewer and lower-income youths by 110 calories.263 calories youths have to consume daily in order Some policy changes to achieve the reduction to achieve the respective goals.260 suggested by the authors include:264 Based on NHANES data and previous trends in n educing consumption of sugar-sweetened R obesity prevalence, weight and BMI among youth beverages (SSB) by replacing all SSBs with ages 2-19, the researchers found that in order water could reduce the per capita caloric in- to halt the rising trend in mean body weight it take by 120 calories per day; would be necessary to eliminate 41 calories per day per capita.261 In order to reach the Healthy n Participating in a comprehensive physical People 2020 goal (to lower childhood obesity by education program among fourth- to sixth- 10% from 2005-2008 levels) it would take a re- graders could result in an additional 19 duction of 64 calories/day per capita.262 calories expended per day; and The research also revealed that much larger n Engaging in an after-school activity program reductions would be needed among low-income for children in grades K-5 could result in an and racial/ethnic minority youths and adoles- additional 25 calories expended per day. cents. In order to reach the Healthy People 62 2. Obesity-Related Legislation for Healthy Communities States also have obesity-related legislation aimed at the general population. These actions include tax policies, menu labeling, restrictions on litigation and planning and transportation policies. OBESITY-RELATED STATE INITIATIVES -- 2012 Has Soda (Sugar-Sweetened State Has Menu Labeling Laws Has Complete Streets Policy Has Limited Liability Laws Beverage) Taxes Alabama 3 3 Alaska Arizona 3 Arkansas 3 California 3 3 3 Colorado 3 3 3 Connecticut 3 3 Delaware 3 DC 3 Florida 3 3 3 Georgia 3 Hawaii 3 3 Idaho 3 3 Illinois 3 3 3 Indiana 3 3 Iowa 3 Kansas 3 3 Kentucky 3 3 Louisiana 3 Maine 3 3 3 Maryland 3 3 Massachusetts 3 Michigan 3 3 Minnesota 3 3 Mississippi 3 Missouri 3 3 Montana Nebraska Nevada New Hampshire 3 New Jersey 3 3 New Mexico New York 3 3 North Carolina 3 North Dakota 3 3 Ohio 3 3 Oklahoma 3 Oregon 3 3 3 Pennsylvania 3 Rhode Island 3 3 South Carolina South Dakota 3 3 Tennessee 3 3 Texas 3 3 Utah 3 3 Vermont 3 Virginia 3 Washington 3 3 3 West Virginia 3 Wisconsin 3 3 3 Wyoming 3 # of States 4 34 + D.C. 17 25 Please Note: Checkmarks in chart above that are in red type represent new laws passed 2011 or 2012. 63 SUGAR-SWEETENED BEVERAGE (SSB) TAXES A number of states have a tax on soda or sugar- say a national soda tax of a penny per 12 sweetened beverages. While many states in- ounces would generate $1.5 billion a year.268 stituted the taxes for revenue purposes, some A 2008 Congressional Budget Office (CBO) proponents of these taxes believe they can have report on options to pay for health reform a health benefit, comparing them to taxes on included a proposal for a federal excise tax of tobacco products. Twenty years ago, cigarettes three cents per 12 ounces of sugar-sweetened were taxed at a relatively low rate. Since then beverage. According to their estimates, this cigarette taxes have tripled, pushing the cost of tax have generated an estimated $24 billion cigarettes higher by an average of 160 percent. between 2009 and 2013.269 Many experts say the increases played a major However, the proposed SSB tax did not gain role in reducing rates of smoking and tobacco- widespread support during the 2009-2010 related disease.265, 266 health care debate. Supporters blame a $24 n According to Bridging the Gap, a nationally million lobbying and advertising campaign by the recognized research program funded by beverage industry, funneled partly through an RWJF, 34 states and Washington, D.C. industry-funded group called Americans Against now impose sales taxes on soda: Alabama, Food Taxes.270 Arkansas, California, Colorado, Connecticut, Voters in Richmond, California and El Monte, Florida, Hawaii, Idaho, Illinois, Indiana, Iowa, California will consider ballot measures for a Kansas, Kentucky, Maine, Maryland, Minnesota, one-cent-per-ounce tax on sugar-sweetened Mississippi, Missouri, New Jersey, New beverages this November.271, 272 The proposed York, North Carolina, North Dakota, Ohio, taxes would require owners of bodegas, Oklahoma, Pennsylvania, Rhode Island, South theaters, and other stores to total ounces Dakota, Tennessee, Texas, Utah, Virginia, sold and then most likely pass the cost on to Washington, West Virginia and Wisconsin.267 customers. If approved, money from the taxes A number of advocates and policy-makers have would go toward fighting childhood obesity examined the impact of potential federal action through more bike lanes, nutritional education on the issue. Researchers at Yale University and after-school sports programs.273 SSBs and Health Many studies link increased consumption of serving of SSBs per day, and 35 percent more at SSBs to negative health outcomes, including risk when they consumed two servings or more obesity, type 2 diabetes and coronary heart dis- per day compared to women who consumed ease.274,275, 276 In the Nurses’ Health Study II, the less than one serving per month.278 risk of diabetes was nearly double for women There is also evidence to suggest that bever- who consumed one or more servings of SSBs ages sweetened with noncaloric sweeteners per day compared to those who consumed less increase caloric intake through consumption than one serving of SSBs per month.277 And, of other calorie sources or by increasing a women were 23 percent more at risk of coro- taste for sweets.279 nary heart disease when they consumed one 64 MENU LABELING Menu labeling — including nutrition information The federal rules, in most cases, will pre-empt on menus and menu boards — is based on state regulations related to menu labeling. the idea that informed consumers make In recent years, several states and localities have informed choices. Leading health organizations, implemented menu labeling laws: including the American Medical Association, want labeling that is easy to understand and n our states — California, Maine, New Jersey F includes information about the total calories, and Oregon — currently have laws that fat, saturated fat, trans fat and sodium content require the posting of nutrition information of food items.280 According to the Yale Rudd on menus and menu boards in restaurant Center for Food Policy and Obesity, 80 percent chains with 20 or more in-state locations. of consumers also want this information.281 Seattle, Philadelphia, New York City, Nashville, San Francisco and Montgomery County, The Affordable Care Act requires chain restau- Maryland also have menu-labeling provisions. rants or food establishments (those with 20 or more locations) to display calorie counts and One state updated menu-labeling legislation be- other nutritional information for standard menu tween June 1, 2011, and June 30, 2012: items. Companies that own or operate 20 or n California passed legislation to align the cur- more food or beverage vending machines have rent California state menu labeling law with similar requirements. the new Federal standards (SB 20, 2011). Front-of-Pack Labeling at Walmart In an effort to make it easier for consumers to sive evaluation process and must meet nutrition identify healthier food items, Walmart recently criteria that, according to Walmart, have been unveiled their “Great For You” icon. Walmart, informed by the 2010 Dietary Guidelines for which is the nation’s largest food retailer, will Americans, FDA, USDA and IOM. The crite- include the icon on select Walmart Great Value ria are available to the public to view online at and Marketside items. Items that bear the www.walmartgreatforyou.com.282 “Great For You” icon have undergone an exten- LEGISLATION TO LIMIT OBESITY LIABILITY Many states have responded to the obesity epi- n Alabama established that a packer, distribu- demic through laws that prevent people from tor, manufacturer, carrier, holder, seller, mar- suing restaurants, manufacturers and market- keter, or advertiser of food shall not be subject ers for contributing to unhealthy weight and to any civil action for any claim arising out of related health problems. These laws have been weight gain, obesity, a health condition as- prompted by corporations that were concerned sociated with weight gain or obesity, or other about potential obesity-related lawsuits similar to generally known condition allegedly caused by the lawsuits tobacco companies have faced. or allegedly likely to result from long-term con- sumption of food (HB 242, 2012). n Twenty-five states have obesity liability laws: Alabama, Arizona, Colorado, Florida, Proponents of these laws argue that obesity is an Georgia, Idaho, Illinois, Indiana, Louisiana, individual choice, a matter of “common sense, and Kansas, Kentucky, Maine, Michigan, Missouri, personal responsibility.”283 New Hampshire, North Dakota, Ohio, Or- Opponents of the laws argue that, in some cases, egon, South Dakota, Texas, Tennessee, Utah, restaurants, food manufacturers and marketers Washington, Wisconsin and Wyoming. withhold crucial information about the dangers of One state implemented obesity liability legisla- their products, and that lawsuits are an appropriate tion between June 1, 2011 and June 30, 2012: way to respond to this unethical or illegal behavior. 65 DESIGNING STREETS FOR ALL USERS To encourage physical activity and green trans- 1. ncorporating sidewalks and bike lanes into I portation, activities that include walking and cy- community design. cling, and building or protecting urban transport 2. Providing funding for biking and walking in systems that are fuel-efficient, space-saving, and highway projects. promote healthy lifestyles, many state and local governments are adopting Complete Streets 3. Establishing safe routes to school. policies. Complete Streets are roads designed to 4. ostering traffic-calming measures (e.g., any F allow all users — bicyclists, pedestrians, drivers transportation design to slow traffic). and public transit users — to access them safely. 5. Creating incentives for mixed-use development. Many parents and children say that concerns about traffic safety keep them from walking According to the National Complete Streets to school.284 According to the 2009 National Coalition, states, counties, regional governments Household Travel Survey, only 13 percent of and cities have passed more than 350 Complete children ages 5–14 usually walked or biked to Streets policies. school, compared with almost half of students n Seventeen states have passed Complete in 1969.285 Conversely, 12 percent of children Streets laws: California, Colorado, arrived at school by car in 1969, compared with Connecticut, Delaware, Florida, Hawaii, 44 percent in 2009.286 Illinois, Maryland, Massachusetts, Michigan, Better traffic safety can promote healthier Minnesota, New York, Oregon, Rhode Island, living. For instance, a 2003 study found that Vermont, Washington and Wisconsin. 43 percent of people with safe places to walk One state implemented legislation between June within 10 minutes of home met recommended 1, 2011, and June 30, 2012: activity levels; just 27 percent of those without safe places to walk met the recommendation.287 n New York established that the state shall An Australian study found that residents are 65 consider the access and mobility on the road percent more likely to walk in a neighborhood network by all users of all ages, including with sidewalks.288 motorists, pedestrians, bicyclists and public transportation users through the use of com- A review by the National Conference of State plete street design features in the planning, Legislatures (NCSL) identified the five policies design, construction, reconstruction and re- that most encourage biking and walking: 289 habilitation of such projects (SB 5411, 2011). 66 National Policy and Legal Analysis Network (NPLAN) and Food Marketing to Youth NPLAN, a project of Change Lab Solutions, The report takes an in depth look at five catego- continues to work to provide information and ries of digital marketing techniques used by food technical assistance for communities interested in marketers to target youths: 293 improving healthy eating and active living. They 1. Augmented reality, online gaming, virtual en- focus on four major categories: healthy commu- vironments, and other immersive techniques nity food systems, healthy schools, healthy land that can induce “flow,” reduce conscious at- use planning and food marketing. NPLAN devel- tention to marketing techniques and foster ops model policies for a variety of topics ranging impulsive behaviors; from model healthy beverage vending policies to model physical activity standards for child-care 2. Social media techniques that include surveil- providers to a model ordinance for produce carts. lance of users’ online behaviors without notifi- cation, as well as viral brand promotion; NPLAN also recently released a report on digi- tal food marketing to children and adolescents, 3. ata collection and behavioral profiling de- D Problematic Practices and Policy Interventions. signed to deliver personalized marketing to Research has found most foods that are marketed individuals without sufficient user knowledge toward young people are high in sugars, fat and or control; salt, and food marketing does have an impact on 4. ocation targeting and mobile marketing, L what youths consume.290,291 The report notes which follow young peoples’ movements and that digital marketing is different from previous are able to link point of influence to point of forms of marketing in that it is multidimensional purchase; and and proliferates a range of social media and online applications through not only exposing youths to 5. Neuromarketing, which employs neurosci- their product, but also by encouraging adoles- ence methods to develop digital marketing cents to interact with the product and integrate techniques designed to trigger subconscious, the brand into their identity.292 emotional arousal. Food Marketing in Maine High Schools In 2007, Maine became the first state to imple- Researchers conducting the assessment also ment a statewide law prohibiting marketing found the following at the sample high schools of foods of minimal nutritional value on public in Maine:298 school grounds. Yet, a recent study released n Nearly 200 different food and beverage by the University of New England found that products were marketed in schools and marketing of junk food is still widespread in each school displayed 49 food or beverage Maine public schools.294 posters and signs on average; Researchers surveyed a sample of Maine high n There were 28 different noncompliant schools, and, while support for the ban was food or beverage products marketed in overwhelming among key administrators, 85 schools, and a significant portion of those percent of Maine high schools still marketed were promoted in athletic areas and unhealthy foods on campus.295 The compli- teachers’ lounges; ance problem appeared to stem from a lack of knowledge about the law. In only 15 percent n The majority of food and beverage posters of the schools, both administrators inter- and signs were in cafeterias (52 percent), viewed had knowledge of the ban on market- athletic areas (16 percent), entrances and ing of unhealthy foods and drinks, and fewer hallways (12 percent) and teachers’ lounges than 50 percent of the schools reported any (12percent); and changes to food marketing practices since the n On average, each school had 5.6 vending ban went into effect in 2007.296 More than machines. three-quarters of schools reported wanting more help and technical assistance in order to meet the requirements of the ban.297 67 B. C DC COOPERATIVE AGREEMENTS TO STATES FOR OBESITY PREVENTION AND CONTROL CDC funds many state and local efforts to pre- and rural areas for evidence-based prevention vent and control obesity and related diseases. and wellness programs. More than half of the Two years ago, through its Communities Put- funds will go toward obesity prevention efforts. ting Prevention to Work (CPPW) program, the The table below provides a summary of these grants. agency awarded $373 million to cities, towns Obesity-Related CDC Cooperative Agreements to States - FY 2011 ARRA Community Nutrition, Physical Coordinated School Healthy REACH Community State Obesity Grants1 Activity & Obesity Grants Health Grants2 Communities3 US4 Transformation Grants Alabama 3 3 Alaska 3 3 Arizona 3 3 3 Arkansas 3 3 3 3 California 3 3 3 3 3 3 Colorado 3 3 3 3 3 3 Connecticut 3 3 3 3 Delaware 3 DC Florida 3 3 3 Georgia 3 3 3 3 Hawaii 3 3 3 3 Idaho 3 3 Illinois 3 3 3 3 Indiana 3 3 3 Iowa 3 3 3 1 While all 50 states Kansas 3 receive some funding Kentucky 3 3 3 3 through the CPPW State and Territorial Initiative, 39 Louisiana 3 3 communities in 28 states Maine 3 3 3 3 receive CPPW Commu- Maryland 3 3 nity funding for obesity. Massachusetts 3 3 3 3 3 3 2 Nez Perce Tribe also Michigan 3 3 3 3 3 receives Coordinated Minnesota 3 3 3 3 3 School Health funding. Mississippi 3 3 3 3 Most Healthy Communi- Missouri 3 3 ties grants are not directed Montana 3 3 3 to States, but are instead Nebraska 3 3 3 3 directed to tribes, local Nevada 3 3 public health departments, New Hampshire 3 3 and community-based organizations. The states New Jersey 3 3 3 3 listed here have at least New Mexico 3 3 3 3 3 one grantee funded by New York 3 3 3 3 3 3 these programs. Healthy North Carolina 3 3 3 3 3 3 Communities funds all North Dakota 3 3 3 States through the Collab- Ohio 3 3 3 3 3 orative Funding Opportu- Oklahoma 3 3 3 3 nity Announcement, but at a minimal level. Oregon 3 3 Pennsylvania 3 3 3 3 4 REACH U.S. grants are Rhode Island 3 3 not directed to States, but are instead directed South Carolina 3 3 3 3 3 to tribes, local public South Dakota 3 3 3 health departments, and Tennessee 3 3 3 community-based organi- Texas 3 3 3 3 zations. The states listed Utah 3 3 3 here are those have at Vermont 3 3 least one grantee funded by these programs. Five Virginia 3 3 3 other states *AL, AZ, GA, Washington 3 3 3 3 3 3 IN, WY) have REACH West Virginia 3 3 3 3 3 3 U.S. grantees whose work Wisconsin 3 3 3 3 3 does not directly relate to Wyoming 3 prevention and control of # of States 28 25 22 50 17 36 obesity-related diseases. 68 C. FEDERAL POLICIES AND PROGRAMS The following section examines key federal laws evidence-based standards developed by CDC and programs affecting obesity. and largely supported by the public. A 2008 survey by NACCRRA reported that 98 per- 1. Let’s Move cent of parents thought child care health and February 2012 marked the two-year anniversary of safety standards needed to be improved. Pro- the Let’s Move initiative, launched by First Lady viders and parents can go to www.HealthyKid- Michelle Obama to raise awareness about the sHealthyFuture.org for these free tools and dangers of the childhood obesity epidemic and resources and to share success stories. Let’s promote comprehensive, multi-sector solutions. Move! Child Care has recognized the efforts of 20 child care programs and networks, includ- The initiative emphasizes healthy eating and in- ing the states of Rhode Island and Idaho. creased physical activity at school, at home and in the community. It has brought together pub- n et’s Move! Indian Country, launched in May 2011, L lic officials, the food industry, faith- and com- is a partnership to address childhood obesity munity-based organizations, advocacy groups on our nation’s Indian reservations within a and others to find solutions. Two of the most generation. The initiative focuses in a culturally recent targeted efforts in the past year include: sensitive way on issues specifically related to nutrition and activity for Native Americans. A n et’s Move! Child Care, launched in June 2011 L tool kit was produce by a Let’s Move! in Indian in partnership with Nemours Foundation, Country interagency workgroup led by the Partnership for a Healthier America, Bright White House, Domestic Policy Council, the U.S. Horizons and the National Association of Department of Agriculture, the U.S. Department Child Care Resource and Referral Agencies of the Interior, the U.S. Department of Health (NACCRRA). The effort helps child care and Human Services, the U.S. Department providers implement standards to promote of Education, and in collaboration with the healthy behaviors and habits for young chil- Office of the First Lady, Centers for Disease dren — a checklist helps providers to im- Control and Prevention, the U.S. Department prove physical activity and healthy eating of Transportation and the Corporation for and limit screen time for children in child National and Community Service. care settings. The practices are based on 2. Implementation of the Affordable Care Act (Public Law 111-248) The Affordable Care Act (ACA) includes a num- least 20 percent of CTG funding is targeted ber of components that could significantly en- to rural and frontier populations. In May hance obesity-prevention efforts, if strategically 2012, CDC announced the availability of an implemented and fully funded. Some of these additional $70 million for a new Small Com- key aspects include: munities CTG grant program, a two-year grant opportunity aimed at improving health in n he Prevention and Public Health Fund. Be- T communities with less than 500,000 people. tween fiscal years 2010 and 2012, $2.25 billion has been appropriated from the Prevention n he National Prevention Council, the National T and Public Health Fund to states and commu- Prevention Strategy and the National Preven- nity-based organizations to support programs tion Council’s Action Plan. In June 2011, the related to public health improvement and National Prevention, Health Promotion, and chronic disease prevention. Despite cuts made Public Health Council (National Prevention to the Fund by the Middle Class Tax Relief and Council)—comprised of representatives from Job Creation Act of 2012 (Public Law 112-96), 17 different departments and agencies—re- the Fund will provide for an additional $12.5 leased the National Prevention Strategy, the billion over the next ten years (FY2013-FY2022). nation’s first comprehensive action plan for im- proving the health of all Americans. The Strat- n ommunity Transformation Grants (CTGs). C egy contains a number of recommendations In May 2011, CDC awarded more than $100 for addressing the obesity epidemic. The U.S. million to 61 states and communities and Surgeon General and other federal officials seven national organizations to implement visited various parts of the country to encour- and disseminate evidence-based strategies to age communities to replicate the strategy at the address chronic disease to achieve key health state and local level by leveraging public and outcomes. Per the direction of Congress, at 69 private resources to prevent disease and pro- intensive obesity counseling for both adults mote better health. The National Prevention and children. Additionally, there are new Council’s Action Plan, released in June 2012, requirements for coverage of preventive ser- identifies more than 200 current commitments vices in the Medicare program, including an the federal government is taking to implement annual wellness visit and new covered preven- the Strategy. Included in that list are efforts led tive services for all Medicare beneficiaries. by the USDA to ensure that foods purchased, n enu Labeling. In April 2011, FDA issued M distributed or served in federal programs and proposed rules implementing new require- settings meet standards consistent with the Di- ments for chain restaurants, similar retail food etary Guidelines for Americans. establishments and vending machines to in- n ssential Benefits and Coverage of Preventive E clude calorie counts on menu boards and have Services. All new group benefit plans will be additional nutrition information available to required to cover any preventive service that customers upon request. A public comment has received an “A” or “B” rating from the period was held later that year, with the regu- U.S. Preventive Services Task Force (USP- lations expected to be finalized by the end of STF), which includes screening for obesity 2012. According to FDA, about one-third of and many obesity-related diseases such as all calories consumed by Americans are from type 2 diabetes and hypertension as well as foods prepared outside the home. 3. Implementation of the Healthy, Hunger-Free Kids Act (Public Law 111-296) n n January 2012, the USDA published a final I is of particular importance because obesity rule containing the first update to nutritional rates tend to be higher among such students. standards for the National School Lunch Pro- n SDA also is due to issue a proposed rule to up- U gram and School Breakfast Program in 15 date the meal patterns for the Child and Adult years. Among other changes, the standards Care Food Program (CACFP), a federal program will help to ensure that students are able to eat: that provides subsidized meals to more than 3 s oth fruits and vegetables every day of the B million infants from low-income families, chil- school week; dren and impaired or older adults. The update s greater selection of whole grain-rich A will be based on a consensus report issued by the foods; Institute of Medicine in November 2010 entitled s nly fat-free or low-fat milk; O Child and Adult Care Food Program: Aligning Di- etary Guidance for All. The report noted that cur- s eals with age-appropriate calorie totals to M rent meal pattern nutrition standards are more ensure proper portion size; and than 20 years old and recommended that new s oods with less saturated fats, trans fats and F standards should be based on updated dietary sodium. guidelines and promote eating more fruits and n n 2012, USDA is expected to publish a pro- I vegetables, whole grains, and other foods that posed rule updating nutrition standards for are low in fat, sugar and salt. “competitive foods,” which include snacks n inally, USDA is due to issue a proposed rule F and drinks sold in school vending machines, in 2012 to help implement expanded require- stores, or à la carte lines that are outside the ments regarding school district wellness poli- school meals program. A recent Health Im- cies. While all school districts participating pact Assessment by the Kids’ Safe & Healthful in federal child nutrition programs were re- Foods Project and the Health Impact Project quired to have a wellness policy in place by the concluded that updating national standards 2006-2007 school year, the law expanded these for the snacks and drinks sold in school vend- policies to help school districts and interested ing machines, stores and à la carte lines would stakeholders promote student wellness, pre- reduce students’ consumption of unhealthy vent and reduce obesity and address other driv- items during the school day.299 The study also ers of disease and illness. In July 2011, USDA found that consistent national guidelines likely issued an implementation guidance memo- would encourage more students to buy break- randum to school districts describing upcom- fast and lunch at school, providing schools ing requirements and is working with both the with extra revenue. Students in lower-income Department of Education Office of Safe and communities and Black and Hispanic students Drug-Free Schools and the CDC to provide would benefit from stronger standards, which technical assistance to local stakeholders. 70 4. Strategic Realignment of Chronic Disease Programs at CDC For fiscal year 2013, President Obama used his changes aimed at addressing chronic diseases budget proposal to urge Congress to condense via more integrated strategies. Aside from the or consolidate several dozen budget lines for the Division for Nutrition, Physical Activity, and CDC Center for Chronic Disease Prevention and Obesity, two new divisions, the Division for Health Promotion into five lines. The proposal is Community Health and Division of Population similar to one made in his fiscal year 2012 budget Health, now house programs aimed at empow- proposal and is aimed at transitioning current cat- ering communities to address chronic diseases, egorical funding for various chronic diseases into including reduction of obesity. a more comprehensive approach to addressing In 2011, the Center initiated a new Coordinated chronic disease. Such an approach could offer Chronic Disease Prevention and Health Promo- improved efficiencies to achieving progress in tion Program with funding from the Prevention addressing obesity and other co-morbidities but and Public Health Fund. The program awarded would need to be thoughtfully designed to ensure grants to all 50 state health departments to help that scarce resources are appropriately spent and build capacity to address chronic disease, in- current investments are improved, not lost. cluding obesity, by focusing on comprehensive Separate from the budget proposal, the Chronic strategies and common risk factors. Disease Center is already undergoing a series of 5. Healthy Food Financing Initiative Nearly 23.5 million Americans live in neighbor- Treasury, and a $250 million set-aside from the hoods where they cannot buy healthy food to New Markets Tax Credit Program). Opponents feed their families. Without access to foods that of the proposal contend that it is an inappropri- can help people stay healthy, obesity rates and ate use of federal resources. health care costs will continue to rise. Improving The program employs a triple aim — creating jobs, the availability of healthy food in underserved economic development, and improving health in communities is an important and proven com- low-income neighborhoods by improving access ponent of a comprehensive strategy to com- to healthy food options to help address obesity. It bat America’s obesity crisis and strengthen the is based on the Pennsylvania Fresh Food Financ- health of our communities. ing Initiative, a public-private collaboration that In 2010, President Obama proposed creating a employed a similar model beginning in 2004. Healthy Food Financing Initiative (HFFI) at the The Pennsylvania FFI has made it easier for an USDA to help bring affordable healthy foods to estimated 400,000 residents to find healthier food undeserved communities. At the federal level, in the neighborhood. It led to the financing of 88 the initiative would be run as a partnership healthy food stores or farm markets in underserved between HHS, USDA, and the Department of rural or urban locations that created or retained Treasury. For fiscal year 2013, the budget pro- some 5,000 jobs in struggling neighborhoods. posal included $285 million (including $10 mil- The Senate’s version of the 2012 Farm Bill in- lion for HHS, $25 million for the Community cludes $125 million for HFFI. Development Financial Institutions program at 6. National Physical Activity Plan Now entering its third year of implementation, fitness and sports; public health; transportation, the National Physical Activity Plan was devel- land use and community design; and volunteer oped by a public-private partnership of orga- and non-profit. Each of the sectors is charged nizations and individuals representing eight with developing strategies and tactics to pro- different sectors: business and industry; educa- mote physical activity across all sectors of Ameri- tion; health care; mass media; parks, recreation, can life — where they work, live, play and learn. 71 7. FDA Front-of-Package Review Congress directed CDC to work with IOM, FDA, n ot simply provide nutrition information but N and the USDA on a study over concerns that the give guidance on the healthfulness of a prod- growing number of types and systems of “front- uct and encourage healthier choices through of-package” (FOP) labeling on food products is simplicity, visual clarity and symbolic meaning; leading to consumer confusion and varying levels n how calories in household servings on all products; S of scientific rigor. As expected, IOM released the second part of the study in October 2011, which n se a point system for saturated and trans U examines consumer understanding of FOP sys- fats, sodium and added sugars where more tems and recommends steps for FDA to take to points conveys that a product is healthier. develop a standard FOP system. The report con- FDA is reviewing the report and has indicated cludes that the standard FOP system should: they plan to propose a new system in the future. 8. Childhood Obesity Demonstration Program CDC announced four-year funding for the new covered under the Children’s Health Insurance Childhood Obesity Demonstration Program in Program (CHIP), a lower-income population for September 2011. The program aims to identity which the obesity epidemic is disproportionately strategies for integrating pediatric clinical care problematic. Funding was awarded to research with community prevention and other support facilities in Houston, Texas; San Diego, Califor- programs to help prevent childhood obesity. nia; and Massachusetts. All funded activities will Community health workers are being used to be evaluated and studied for scalability. The pro- help link families with community programs, gram was authorized by the Children’s Health health insurance enrollment and other resources Insurance Program Reauthorization Act of 2009 for disease prevention and management. The (Public Law 111-3) and funded by the ACA to the project is focused on children ages 2-12 who are tune of $25 million for 2010-2014. 9. USDA Fruit and Vegetable Program Expansion In early 2012, USDA issued a proposed rule to ex- healthy eating habits. An independent evaluation pand and improve the Fresh Fruit and Vegetable of the program found that the FFVP increases the Program (FFVP), an initiative that provides fresh consumption of fruits and vegetables by 15 percent fruits and vegetables to more than 3 million chil- in participating schools on days when the program dren in 4,600 elementary schools in low-income is implemented with no increase in total caloric in- neighborhoods. The program seeks to not only im- take. Further, many school districts have reported prove access to fruits and vegetables but also educate that popular fruits and vegetables served in the school-age children on the importance of lifelong FFVP are now served in participating school meals. 10. Surface Transportation Law Federal transportation policy impacts how all 33 percent cut from the $1.2 billion appropri- Americans move around in their day-to-day ated in FY2011 to the three individual programs. lives, and provides a significant opportunity to A new provision also allows states to opt-out of encourage more Americans to walk, bike and half the funds dedicated to small-scale walking employ other forms of physical activity routinely. and biking projects It also includes new restric- tions that could limit opportunities for public In July 2012, President Obama signed a two- health and other stakeholders to participate in year extension of the federal surface transpor- the transportation planning process. tation authorization that included a number of changes to current law. The law does include a provision that provides grants to local communities for street-scale The law eliminates dedicated funding for Safe improvements dedicated to safer walking and Routes to School, Recreational Trails and Trans- biking. However, a number of health-related portation Enhancement programs. Instead, measures supported by public health advo- these and other active transportation programs cates—including a Health Impact Assessment are combined into a new entity called Transpor- or Complete Streets provision—were not in- tation Alternatives. Funding for this new entity cluded in the final legislation. has been authorized at $800 million annually, a 72 11. National Initiative for Children’s Healthcare Quality In September 2010, the Health Resources and Ohio State University (Ohio), ArCare (Arkan- Services Agency (HRSA) awarded $5 million from sas), Children’s Mercy Hospitals and Clinics the Prevention and Public Health Fund to the Na- (Missouri), Yellowstone City County Health De- tional Initiative for Children’s Healthcare Quality partment (Montana), Scripps Family Medical (NICHQ) to support the creation of a new Pre- Residency Program (California), and Lincoln vention Center for Healthy Weight. In addition County Health Department (Washington). to identifying health care systems strategies for The communities are working to promote preventing and reducing childhood obesity, the collaborations between primary care, public initiative also launched the Healthy Weight Col- health, and individuals and families towards ad- laborative and expanded to include health care dressing the obesity epidemic. Phase two of the and public health partners in ten new communi- collaborative is expected to launch sometime in ties in 2011, including: 2012 with the addition of 40 additional teams n oston Children’s Hospital (Massachusetts), B across the country. Evaluation of phase one has Greater Rochester Obesity Collaborative (New already started and is expected to assess the York), St. Charles Health Council (Virginia), quality and effectiveness of the Healthy Weight. Community Health Improvement Partnership Learning purpose of this evaluation is to assess (Florida), Nationwide Children’s Hospital/ the quality and effectiveness of these activities.  12. Upcoming Legislative Opportunities a. griculture Appropriations Act and Fiscal A tainable and have prioritized reductions in spend- Year 2013 ing to achieve deficit reduction targets. A number of important programs that are ap- propriated through the annual agriculture b. Farm Bill Reauthorization appropriations bill provide opportunity to pro- The Farm Bill helps to guide our nation’s over- mote and support healthy eating, particularly all agricultural policy and has a major impact in among low-income populations that are dispro- providing all Americans with access to healthy, portionately impacted by the obesity epidemic. affordable food choices. In fact, nutrition assis- SNAP helps put food on the table for more than tance programs have historically accounted for 46 million Americans and cuts to this program more than two-thirds of total Farm Bill funding. threaten beneficiaries’ ability to access healthy A number of provisions in the nutrition title are foods. Similarly, the Special Supplemental aimed at protecting against hunger while pro- Nutrition Program for Women, Infants and moting nutritious diets, such as SNAP and The Children (WIC) provides nutritional food, edu- Emergency Food Assistance Program (TEFAP), cation and health care services to more than 9 while others, like the SNAP Nutrition Education million women and children younger than age and Fresh Fruit and Vegetable Program, help 5 to help support and promote healthy weight to improve consumption of healthy foods, nu- and development. Other funds in agriculture trition and health outcomes among vulnerable appropriations legislation help support: populations. Funding for the National Institute n reastfeeding peer counselors to help women ini- B of Food and Agriculture helps to ensure that tiate and sustain proper breastfeeding, a proven vital and basic research on nutrition, hunger strategy to reducing pediatric obesity prevalence. and obesity prevention is carried out. The Farm Bill also supports community-based nutrition n rants to school meal programs to upgrade G approaches, like supporting farmers’ markets kitchen equipment to serve healthier, safer and Community Food Projects, that have an im- meals and initiate breakfast programs. pact on the crops and food products that are n armers’ market vouchers for low-income F available in various communities. women, infants, children, and seniors. Additional opportunities exist to further incen- Annual appropriations bills, which are responsible tivize healthier eating and make healthy food for setting levels of federal discretionary spending, choices accessible and affordable. For example, are often a flashpoint in congressional debates steps to improve the purchase and consumption over the size and scope of the federal government. of fruits and vegetables at farmers’ markets and Supporters of federal nutrition programs contend similar healthy food retailers, such as a SNAP in- that they are a vital element of the social safety net centive grant program or enabling EBT benefits, for low-income families and children. Opponents could be taken. contend that funding for such programs is unsus- 73 The House Agriculture Committee’s version of Department of Education and reauthorize the the bill proposes a cut of around $16 billion to Carol M. White Physical Education Program. SNAP. The Senate version of the bill proposes a In March 2011, Senator Tom Harkin (D-IA), and $4.5 billion cut to SNAP. Representatives Ron Kind (D-WI) and Jim Gerlach Debate over reauthorization of the Farm Bill (R-PA) reintroduced the Fitness Integrated with is deeply influenced by larger debates over Teaching (FIT) Kids Act (S. 576, H.R. 1057). The the size and role of the federal budget. As the bill would require local education agencies and SNAP program encompasses such a large por- school boards to publish how much progress they tion of total Farm Bill spending, differences in have made in meeting national standards for physi- opinion over the value and effectiveness of the cal education and activity. The legislation would program have resulted in considerable variation also expand efforts to hire more physical educa- in the proposed level of total Farm Bill funding. tion teachers, fund research on how health affects The arguments are similar to the agriculture ap- academic achievement, and explore new ways to propriations bills discussed in the prior section. promote physical education in schools. Among Supporters of maintaining or expanding SNAP the many provisions of the Fit for Life Act (H.R. funding say that the program is a vital element of 2795) introduced by Representative Marcia Fudge the social safety net that also helps stimulate the (D-OH) is a new Department of Education grant economy. Opponents, meanwhile, believe that program to secondary schools to establish health the program has grown too large with respect and fitness programs in low-income communities. to both funding and number of people served, Respective pieces of legislation introduced and particularly in light of the current budget deficit. considered by respective House and Senate com- mittees of jurisdiction for ESEA differ in their c. Elementary and Secondary Education Act approach to promoting physical activity and nu- Reauthorization trition. The Senate HELP Committee bill would School districts and community organizations eliminate the PEP program, but a broader ‘Suc- that implement comprehensive physical fit- cessful, Safe and Healthy Students’ grant program ness and nutrition programs for students are would provide funding to states and localities for eligible for competitive Carol M. White Physical physical activity, fitness, and nutrition programs. Education Program (PEP) grants, authorized by The Senate HELP Committee bill also would per- the Elementary and Secondary Education Act mit states to use federal core education funding to (ESEA). The program was funded at $78.7 mil- support physical and health education curriculum. lion in FY 2012, which permitted the U.S. De- The House Education & Workforce Committee partment of Education to award 56 additional passed legislation that would eliminate 41 federal grants in 2012 in addition to meeting additional education programs, including the PEP program. obligations for grantees that were already in the middle of a three-year grant cycle. ESEA reauthorization legislation that has been ap- proved by the Senate HELP Committee and the However, despite this limited grant opportunity, House Education & Workforce Committee repre- there is no federal requirement regarding content sent two competing visions for the role of federal or scope of the nutrition education curriculum government in supporting physical education for schools that receive federal funding. ESEA funding. The Senate approach would continue reauthorization therefore provides a number of federal funding for physical education programs opportunities to address the obesity epidemic by and would expand core curriculum funding op- both promoting healthy eating and increasing portunities to include physical education; support- physical activity among school-age children. ers contend that federal funding is particularly Studies also have demonstrated that increased important in light of state and local budgets cuts physical activity is linked to improved academic that have eliminated physical education programs performance, better behavior and reduced tru- across the country. The House approach would ancy. Moving physical and health education to discontinue federal funding for such programs “core” subjects would ensure that schools have amidst a larger elimination of federal education the option to use Title I and Title II funds for programs generally; supporters of this approach similar programs, such as those included in Sen- contend that overly prescriptive federal require- ator Tom Udall’s (D-NM) Promoting Health ments for schools infringes on state autonomy to for Youth Skills in Classrooms and Life (PHYSI- tailor and implement education programs that CAL) Act (S.392). The Act would also create meet students needs and achieve results. an Office of Safe and Healthy Students in the 74 D. EXAMPLES OF PREVENTION IN ACTION Where a person lives, learns, works, plays and faith-based organizations and schools are taking prays has a significant impact on his or her action to make healthy choices easier for their health. The following section focuses on exam- neighbors, employees, congregants and students. ples of how some communities, small businesses, EVIDENCE-BASED PROGRAMS CAN IMPROVE NUTRITION, INCREASE PHYSICAL ACTIVITY AND REDUCE OBESITY n The New York Academy of Medicine (NYAM) identified especially in a high risk group. The intervention consisted 84 peer-reviewed studies of effective, community-based of a 40-hour educational curriculum delivered over a disease-prevention programs.300 For example: 30-day period with clinical and nutritional assessments s n Pawtucket, Rhode Island, the Pawtucket Heart Health I before and after the educational component, in which Program conducted an intervention to educate 71,000 participants were instructed to optimize their diet, people about heart disease through a mass media cam- quit smoking, and exercise daily (walking 30 minutes paign and community programs. Five years into the inter- per day). At the end of the 30-day intervention period, vention, the risks for cardiovascular disease and coronary stratified analyses of total cholesterol, LDL, triglycerides, heart disease had decreased by 16 percent among mem- blood glucose, blood pressure and weight showed bers of the randomly selected intervention population. significant reductions with the greatest improvements among those participants at highest risk. s esearchers at Ohio State University recruited 60 women R in their forties for a 12-week walking program that took n CDC’s Community Preventive Services Taskforce conducts place on the college’s campus. At 3 months, the intervention a systematic review and evaluation process to determine group saw a 1 percent decrease in body mass index, a 3.4 effective programs and policies for improving health and percent decrease in hypertension, a 3 percent decrease in preventing disease. Its Community Guide has identified cholesterol, and a 5.5 percent decrease in glucose. a series of evidence-based, community approaches that s The Rockford Coronary Health Improvement Project have resulted in increased physical activity, good nutrition in Rockford, Illinois was a community-based lifestyle promotion, lowering diabetes rates, reducing obesity and intervention program aimed at reducing coronary risk, other prevention goals.301 Spotlight on Evidence-Based Prevention:  Diabetes Prevention Program (DPP)302 One of the most promising evidence-based programs in tion Recognition Program, assures quality and fidelity to the the country is the National Diabetes Prevention Program science and aids in facilitating reimbursement. Another key (National DPP). It is based on the Diabetes Prevention Pro- part of the program is working closely with employers to gram Research Study that was led by NIH and supported by offer the lifestyle change program as a covered health benefit CDC. The study demonstrated that modest weight loss of 5 and engaging insurers to reimburse organizations delivering percent to 7 percent and increased physical activity to 150 the lifestyle change program using a pay for performance minutes a week through a lifestyle change program reduced model of reimbursement, both are critical to long-term sus- the risk of developing type 2 diabetes by approximately 58 tainability of preventing type 2 diabetes in this country. percent. The National DPP was developed to move this The YMCA of the USA and UnitedHealth Group (UHG) research into practice. It is a great example of public-private are inaugural partners in the National DPP. In the past two partnership; National DPP includes community organiza- years, the YMCA’s DPP (partially funded by CDC and UHG) tions, private insurers, employers, healthcare organizations, has trained more than 800 lifestyle coaches, started more and government agencies working together to reduce the than 300 classes in 30 states around the country, and served number of new cases of type 2 diabetes. nearly 6,000 participants, one-third of whom have finished The lifestyle change program component is delivered by a the program.  Participants in the Y’s program lost an average trained lifestyle coach in a group setting over 12 months that of 4.8 percent of their body weight, while hundreds of indi- includes 16 weekly core sessions and 6 monthly maintenance viduals lost an average of 7 percent of body weight. sessions. Part of the National DPP, the Diabetes Preven- 75 1. Examples of Some New Evidence-Based Prevention Programs in Communities The following are examples of how local or physical activity, and in some cases have communities have launched prevention leveraged resources from CDC grants and initiatives to focus on obesity, nutrition and/ other support. Increasing Access to Healthy Foods in the Community n In late 2011, two pilot public farmers’ hoods, including more than 11,000 low-income markets selling fruits and vegetables opened African-American children and adults. in Birmingham, Alabama. Additional n A grand opening was held for the revitalization communities have been identified for market of one of the oldest gardens in Boston, Mas- development in the coming year, with sachusetts. Nightingale Community Garden estimates that they could potentially reach is now a hub for building a strong social com- 96,000 Birmingham residents. munity through activities such as neighborhood n Over 60,000 North Little Rock, Arkansas cookouts, gardening classes and Senior Fit4Life residents may benefit from increased access group classes. It is estimated that at peak, each to and support for community gardens and plot will produce approximately $430 worth of limited agricultural activity. fresh produce, totaling $54,000 in 2012 alone. n Community gardens in San Diego, Califor- n In Hamilton County, Ohio, over 9,000 nia can now be established on any piece of residents now benefit from increased access vacant commercial or residential land, with to farmers markets and community gardens, the exception of land in coastal communities, new playground equipment in public spaces, and growers will be able to sell their produce and a partnership with community churches in commercial and industrial zones. to purchase basketball hoops and benches for installation in church parking lots. n Chicago, Illinois now allows produce sales at community gardens, adds flexibility in the n Six counties that make up the Mid-Ohio Val- fencing and parking requirements for urban ley region in West Virginia finalized agree- farms, and permits innovative food produc- ments between individual convenience stores tion techniques such as aquaponics, which is a and the Mid-Ohio Valley Health Department system of cultivating both fish and produce. that requires stores to sell fresh fruits and vegetables for two years and display “Change n esidents of Evansville, Illinois celebrated R the Future WV” signage. Over 140,000 the opening of Riverside Foods, a newly reno- residents live within the region and will have vated corner store that accepts SNAP benefits. greatly improved access to fruits and vegeta- Fresh fruits and vegetables are now available bles at their local convenience stores. to residents in nearby underserved neighbor- Increasing Access to Healthy Foods in School and Child Care n School districts in Tri-County, Colorado 30 minutes of screen time per week for children substantially enhanced school district well- over two years old. ness policies to align with IOM standards for n Every public school student in Portland, school nutrition, benefiting over 200,000 Maine now has access to a fruit and vegetable students. Tri-County schools now promote bar or a more traditional salad bar as part of the non-food or healthy food-related parties or lunch program. This initiative not only aims to rewards in the classroom, opportunities for increase fruit and vegetable consumption for increased weekly physical activity, a district about 7,000 students, but incorporates locally wellness council, enhanced communications grown food through Farm-to-School Programs. with parents, standards for school-based food marketing and staff wellness. n In Philadelphia, Pennsylvania, Get Healthy Philly introduced 91 breakfast carts in 60 n Child care providers in Bartholomew County, schools to improve participation in the dis- Indiana now ensure children in these programs trict’s free meal program. These carts make receive at least 60 minutes to 120 minutes of healthy breakfasts available to more than physical activity every day, healthy food options, 37,000 children as they enter school grounds. nutritionally appropriate beverages, and less than 76 Improving the Built Environment to Increase Physical Activity n uring the fall of 2011, Portland, Maine unveiled its first Sto- D n enderson City, Nevada is working to ensure a well- H ryWalks in two parks in the Portland Housing Authority neigh- distributed system of local trails and implement street, pe- borhood. A StoryWalk is a path along which signs are posted destrian, and bicycle connections between neighborhoods showing pages of a book, as well as suggested exercises chil- and services, parks, and transit. The current population of dren can do to mimic the characters and actions in the book. Henderson is 277,502, of which 86 percent now live within a half-mile of a trail. n The New Balance Hubway Bike-Sharing Network began to sup- port active transportation while providing residents with more n The Nashville, Tennessee GreenBikes initiative officially opportunities to be physically active in Boston, Massachusetts. launched with an expansion from two to six locations and The new bike-sharing network is made up of 61 stations and more over 50 bikes. Participation has been robust with more than than 600 bikes. At least seven stations are located in low-income 500 people who have used the program. It is estimated that neighborhoods and subsidized memberships are available for any at the final expansion of the program over 635,000 Nash- low- income Boston resident wishing to become a member. ville residents will have access to the free GreenBikes to improve their levels of physical activity. n A new establishment in Minneapolis, Minnesota Venture North Bike Walk & Coffee, offers new and pre-owned n The 51,000 residents of La Crosse, Wisconsin became bikes, safety riding equipment and all types of walking gear the first Wisconsinites to benefit from “Green Complete at affordable prices for local residents. In addition, they re- Streets,” which blends multimodal transportation planning pair bikes, and provide jobs and training for local youth. and design with best practices in storm water management. YMCA HEALTHY CHANGES IMPACT UP TO 46 MILLION PEOPLE303 Communities around the country engaged in the YMCA’s s 85 schools have added or expanded recess 2 Healthier Communities Initiatives (Pioneering Healthier Com- 4. orking with schools to improve access to healthier W munities, Statewide Pioneering Healthier Communities, and food and drinks. ACHIEVE) are making healthy choices easier for families.304 s ,009 schools changed the food available in their vending 1 A sample of 153 of the Y’s sites found that local leadership machines or sold outside of the lunch line has helped make more than 26,000 improvements to com- munities.305 This work has been carried out with funding s ,334 schools changed their lunch menus to offer 1 from CDC and RWJF. healthier choices s 45 schools expanded their participation in the USDA free/ 3 Some of the changes local leaders have made have helped reduced breakfast or in the afterschool snack program communities by:306 1. ncreasing the amount of fresh fruit and vegetables avail- I 5. Advancing changes in early childhood or afterschool able in neighborhoods. programs to incorporate more physical activity and offer healthier foods and beverages. s 6 new or improved grocery options 8 s ,091 early childhood or afterschool sites have made 2 s 59 new community gardens 4 their snacks or meals more healthy s 0 new healthy corner stores or bodegas 4 s 1,107 early childhood or afterschool sites have made s 7 pricing strategies –either incentive or disincentives— 7 water the primary beverage of choice for snacks and meals to promote the purchase of healthier foods s ,427 early childhood or afterschool programs limit the 1 2. Encouraging changes in the built environment. amount of screen time s 94 sidewalks designed or improved 1 s ,280 early childhood or afterschool programs have added 2 or increased the amount of physical activity to their curricula s 1 zoning guidelines to encourage increased physical ac- 6 tivity or availability of health eating options 6. Helping worksites incorporate healthier food/beverage s 23 “Complete Streets” projects to improve access to 1 options and improving opportunities for physical activity. streets for all users including bicyclists, pedestrians and s 519 worksites increased the number of healthy vending people with disabilities machine options 3. orking with schools to increase physical education and W s 25 worksites improved food choices available in meetings 6 physical activity. s ,127 worksites created incentives for employees to be 1 s 5 new schools that are located to encourage walking 7 active or learn about nutrition and biking to school s 68 worksites encouraged employees to commute in 2 s ,132 schools added or improved physical education criteria 1 more active ways s 15 schools have instituted classroom physical activity breaks 7 s 12 worksites promote and support breastfeeding 2 77 2. Examples of Small Business Approaches to Supporting Wellness in the Workplace and Beyond Businesses around the country are feeling the n mall business owners often feel that they S strain of high health care costs. Many compa- don’t have the resources or the money to set nies provide wellness programs because they up and run wellness programs; and can simultaneously save money while helping n n some cases, given the relatively small num- I employees improve their health. ber of employees, some owners have concerns Chronic diseases such as diabetes, heart dis- that wellness programs will impinge on privacy. ease and cancer are a key driver of health costs. The expert panel also suggested several solu- Wellness programs help not only by lowering tions, including: costs but also by improving employee morale and productivity. n ederal, state and local governments can offer F increased tax credits and other incentives and Wellness programs can be especially important to assistance to help small business wellness pro- small businesses: these companies employ about grams get off the ground; half of the country’s private sector workers and face growing health care costs and lost productiv- n nsurance plans can offer incentives to small I ity related to obesity.307 However, they can also businesses who offer wellness programs; present unique challenges. Currently, 65 percent n ommunity-based organizations such as C of small businesses offer at least some kind of well- YMCAs can collaborate with small businesses ness program, compared with 90 percent of large to increase opportunities to exercise; businesses.308 The definition of small business can vary depending on the sector; for instance for n ocal hospitals can offer free health screen- L wholesale, small businesses have a maximum of ings and classes on nutrition; 100 to 500 employees and in manufacturing, the n ederal, state and local governments and F maximum can range from 500 to 1,500 depend- health and community organizations can ing on the type of product manufactured.309 educate small businesses about the benefits In December 2011, TFAH and the Small Business of wellness programs; and Majority convened more than 20 experts from gov- n ellness programs can become a key part of the W ernment, business, public health, unions, insurers, Health Insurance Exchanges that are due to ar- insurance brokers and small business owners to rive in 2014 as part of the Affordable Care Act. discuss opportunities and challenges for increas- ing the update of and participation in workplace Other key issues raised at the meeting include:: wellness programs by small businesses, particularly n mall businesses can have advantages over S through opportunities available through the im- larger companies in setting up wellness pro- plementation of the Affordable Care Act.310 The grams. Because smaller companies don’t meeting focused on concerns that small businesses have as many management layers, setting up a with 100 or fewer employees may have. wellness program is often simpler, and having The group of experts identified a number of fewer employees makes it easier to communi- challenges small businesses face when consider- cate the program’s importance and benefits; ing wellness programs, including: n t many small companies, employees form a A n here is a lack of data on how wellness pro- T close-knit group, so it is easier to change work- grams help small businesses, in terms of place culture. One employee’s success — re- health and the bottom line; ducing weight or stopping tobacco use — can reverberate throughout the entire company n here is often little information easily avail- T in a way that is less likely to occur at a larger able to small businesses about how to set up a operation; and program and what it should include; n mall businesses may have more incentive S n any small business owners and employees M than large companies to develop effective well- remain unaware of the potential benefits of ness programs. Because small companies have wellness programs; fewer employees, when one person is absent or n here are few models designed to work for T less productive due to a health problem, this the various sizes of small business; has a larger effect on the bottom line. 78 In 2011, CDC announced a $9 million, two- (NHWP), the effort will provide expertise, sup- year program to help 100 small, mid-sized, and port and funding to select companies.311 large businesses around the country set up and The following are three examples of small businesses run evidence-based wellness programs. Known that have independently started workplace wellness as the National Health Worksite Program programs to help their employees improve health. Creative Craftsmen Creative Craftsmen, a custom metal fabrication thanks to an Indiana tax credit that helped de- company in Evansville, Indiana, makes parts for a fray companies’ wellness program costs. How- range of products, including reclining chairs, lawn ever, that credit was suspended for 2012.314 mowers and automobile assembly lines. It has The program is managed by Emily Boyd, a health operated as a small business since Eisenhower coach at Deaconess. With her help, the company was president. now has a solid program. One key to the company’s longevity has been its One key piece of the effort is an annual screen- skilled workforce. Keeping this workforce healthy is ing program that checks employees’ BMI and crucial to its continued success. body fat levels, and tests for diabetes, high Most of the company’s 18 employees are middle- blood pressure and high cholesterol. Waggoner aged males — the average age is a little over 50. said that 90 percent of employees participate According to Melody Waggoner, the company’s in the screenings. Through the screenings and human resources manager, about two-thirds of conversations with employees, Boyd found that these workers are either obese or overweight. a significant number of Creative Craftsmen’s employees needed to manage their weight, ex- Like many smaller companies, Creative Craftsmen ercise more and improve their diet. does not have a large staff or budget for human resources or health care. It is a family-owned She helped them develop plans to improve on business, and Waggoner, who is the daughter of areas that fell into the risky category, and regu- one of the owners, wears several hats, including larly checks in on the participants' progress. human resources manager and accountant. Spouses are also eligible for the screenings, as well as a free flu shot. In 2007 Creative Craftsmen started a wellness pro- gram to help employees exercise more, eat health- In some cases, the screenings have had a sig- ier foods and stop smoking. The company hired a nificant impact. For instance, two years ago, local health care provider, Deaconess Hospital, to tests revealed that the company’s owner and set up and run the program. By taking this step, founder, Tom Pfender, had diabetes. At the Creative Craftsmen is rather unique: according time, Pfender (who is Waggoner’s father) had to a 2011 survey by the Kaiser Family Foundation, no idea that he had the disease. Since then, he just 12 percent of small businesses set up their own has begun exercising and is eating healthier. As wellness programs. The rest have programs that a result of these changes, and the medication he are provided by their health plan.312 now takes, his diabetes is under control. Waggoner said the company started the pro- Boyd said that employees at Creative Crafts- gram because its owners believe that healthier, men are sometimes set in their ways, and can be happier employees are more productive. Again, reluctant to alter their behavior. In 2012, she is this puts the company in the minority: the trying a new, incentive-based approach to make Kaiser survey also found that one-quarter of it easier for them to make healthier choices. small employers offered a wellness program She said that some of the company’s employees to improve employees’ health, while 9 percent have quit smoking or lost a significant amount offered it to improve morale and productivity. of weight. In some cases, however, they have Nearly half said they offered a wellness program started smoking again or regained the lost weight. because it was part of their health plan.313 But Boyd remains optimistic about their long- Currently, the company, whose annual sales term success. “[The backsliding] usually has to do range between $2.5 million and $3.5 million, with stress,” she said. “I want to help them figure spends about $4,000 a year on its wellness out how to make more lasting changes.” This program. Through 2011, Creative Craftsmen year, she has focused especially on working with was reimbursed for half the cost of its program employees who continue to use tobacco. 79 Every year, the company holds wellness con- metalwork involves a fair amount of upper body tests, with varying rules and goals. Some have manual labor, workers at Creative Craftsmen focused on losing weight and decreasing body generally scored high on strength measures. But fat, while others have focused on increasing time the tests showed that many workers lacked flex- spent exercising. One competition awarded ibility. Afterwards, Boyd showed workers how contestants points for every 15 minutes they to stretch. In September she will retest them to spent exercising; for every serving of fruits or see whether they improved. vegetables they ate; for every 8 ounces of water In addition to these contests, the company has a they consumed; and for every driving trip they standing offer: a $100 bonus to any overweight took while wearing a seat belt. Points were also or obese worker who loses weight and keeps it awarded for not eating red meat. Some contests off for three months — or to any employee who involve teams, while others are individual. Prizes quits smoking for six months. have included gift cards and up to $100 in cash. This year, Boyd also set up “lunch and learn” This year, the company is holding a contest that sessions, in which a speaker talks to employees runs from April to September. Every month, about a wellness topic. Recently she brought in workers are eligible to earn entries into two a physical therapist to explain the importance of separate drawings. One awards relatively small stretching to prevent injuries — both on the job prizes such as gift cards. The other will give and during leisure time. out a single, larger prize: an extra personal day. Boyd structured the contest so that every em- Boyd firmly believes in the value of company ployee can participate. wellness programs. “At a lot of companies I’ve worked with, insurance claims go down,” she said. In April, as part of the contest, Boyd tested en- “Employees’ health can really improve through trants on a range of strength and flexibility mea- these programs. And the companies save money.” sures, including grip and biceps strength. Because 80 Explorer Pipeline As human resources manager for Explorer Pipeline in Tulsa, healthier food at meetings. A committee of eight employees Oklahoma, Michelle Griffith oversees the company’s wellness began developing ideas, and in 2008, Explorer rolled out its program, which includes an incentive program for employees program. The effort includes an incentive program that pays em- who exercise, seminars, a health fair and an email newsletter. ployees $30 per quarter if they reach certain health-related tar- Griffith, a fitness buff, is an enthusiastic participant in the pro- gets, such as taking an annual physical, participating in a wellness gram herself. Among other activities, she runs several times a seminar, running in road races, and taking certain vitamins, as well week during lunch with a group of Explorer employees. as prescribed medicines. Every week, Griffith sends employees a weekly email that includes articles on wellness and health recipes. Griffith takes pride in her company’s program. “We’ve had people quit smoking,” she said. “We’ve had people lose In the past two years, Griffith has added new features to Ex- weight, and we’ve had people start exercising more.” plorer’s effort. Every month, the company holds seminars on a range of health- and wellness-related topics. Recent semi- The company owns and runs a pipeline that transports crude nars have focused on strategies to improve diet and nutrition, oil, jet fuel, diesel fuel and other petroleum products from and stress management. The meetings take place at the Tulsa Port Arthur, Texas to Indiana. Nearly 1,900 miles long, the headquarters; to ensure that workers in other locations don’t pipeline handles about 200 million barrels a year. Half of the miss out, the seminars are videotaped and webcast. company’s 200 employees work in Tulsa, while the other half work at seven locations spread along the length of the Explorer also puts on an annual health fair. It offers flu shots, and pipeline. These workers run the gamut, from accountants to screenings for high blood pressure, high cholesterol, diabetes, and secretaries to pipeline repair experts. other ailments. In 2011, Griffith helped start a lunchtime walking and running program. A few times a week, groups of employees Although it has a dispersed workforce, the company feels a in the Tulsa office walk or run together for between 30 minutes strong loyalty to its employees. “Since we’re a small com- and an hour. “It’s a great way to break up the day,” said Griffith. pany, we’re close-knit,” said Griffith. “We’re like a family. The program also reimburses employees up to $50 a month for And we want to take care of our family.” their health club membership. To get the discount, workers must Explorer’s wellness program was started in 2007 by former go to the club at least eight times a month. CEO Tim Felt. A former U.S. Army captain who graduated So far, she said, about one-quarter of the company’s workers from West Point, Felt believes strongly in the value of wellness are participating in at least some part of the voluntary and the importance of healthy living. wellness program. Felt said that the wellness program not only helps employees’ To entice employees to participate, the program includes health, but can also improve the bottom line. “The company is regular health challenges. Every three months, Explorer en- paying a significant amount of employee health care costs,” he said. courages workers to improve on a specific aspect of wellness: “That means I’ve got a vested interest in keeping workers healthy. eating five servings of fruits and vegetables a day, or exercising So there’s a financial interest — and it’s just the right thing to do.” for at least 30 minutes at least five times a week. There is evidence to support him: in a 2010 review of stud- A significant percentage of the company’s employees work ies on wellness, researchers at the Harvard School of Public outside; these workers have somewhat different health con- Health found that for every dollar a company spends on well- cerns than do more sedentary office workers. In the summer ness programs, it saves about $3.27 in medical costs and about of 2011, for instance, the company focused on encouraging $2.73 on absentee costs.315 employees to drink enough water every day — something that Felt, who is now the CEO at Colonial Pipeline outside Atlanta, is especially important for those working outside in the heat. said that the idea for the program first occurred to him at a Griffith said that it is difficult to gauge how much money the company meeting at which donuts were the featured snack. wellness program has saved the company. But she notes that Afterwards, one overweight employee came up to Felt and the company’s health insurance costs have not risen over the said it was hard to lose weight in an environment in which past few years. The overall number of health insurance claims high-calorie foods were the only choice. “From that point on,” filed by employees has also dropped. Felt said, “I decided that if the company was paying for the food, there was going to be a healthy alternative.” At future Felt, the company’s former CEO, agrees that calculating meetings, fruit and water were always part of the offerings. savings from wellness programs is tricky. But he is confident that the programs can have a positive influence on employees Felt said the new policy made a difference. “It’s amazing how — so confident that he has started a wellness program at his many people will eat the fruit or drink the water, if you make new company too. it available,” he said. “This is about helping employees to go in the right direction in Felt, who regularly bikes, lifts weights and works on an ellipti- terms of their health,” he said. cal trainer, then expanded Explorer’s program beyond serving 81 Corporate Network Services Three years ago, Karen Kalantzis decided that she wanted to do Although the wellness program is voluntary, Kalantzis encour- something to encourage her employees to improve their health. ages CNS workers to take part. Last year, she began tracking participation. By collecting and using these metrics, she hopes The majority owner and CEO of Corporate Network Services to learn to reach those who so far aren’t interested. “If we (CNS), an information technology services firm with offices see we’re not reaching our goals,” she said, “we follow up in suburban Washington, D.C. and Florida, Kalantzis saw that with people.” many of her employees were not as healthy as they could be. They weren’t getting enough exercise, and weren’t eating as For the past two years, the company has held a holiday weight- well as they could either. loss competition that begins before Thanksgiving and lasts until after New Year’s Day. Employees put in $20 each, and the Many of the company’s 47 employees are in their 20s and 30s, company matches half of that. Any employee who loses weight but Kalantzis worried that they were on the road to a range of is eligible to win some of the money. Kalantzis estimates that health problems, such as diabetes, cancer and heart disease. during the 2011 contest, about 15 people lost weight, winning IT work tends to be sedentary, with employees spending between $20 and $40 each. “People were into it,” she said. hours at their desks staring at computer screens. As part of the contest, the company holds a healthy holiday The company began by holding an employee health fair. Each potluck party, in which people bring in low-calorie versions year, the fair features a variety of stations, including a table for of their favorite recipes. For instance, someone might bring checking vision; one for gauging blood pressure; another that in a dip that uses reduced-fat cream cheese rather than the allowed workers to try on “beer goggles” that simulated how full-calorie version. After the party, the company posts the alcohol effects perception and coordination; and a space where a recipes on its internal website. Zumba instructor demonstrated the popular exercise technique. Her efforts are garnering notice. In 2011, the Washington Kalantzis, who formerly worked for Hewlett-Packard and Business Journal named CNS one of its 40 healthiest employ- other large IT companies, hopes the program, which costs ers in the Washington area.316 about $4,500 a year, will make the company more efficient, ultimately saving money. She said that while it may not lower CNS encourages health in other ways too. It added medical health insurance premiums, there are other ways in which it monitoring equipment to its offices, including blood pressure can save money. “Increasing presenteeism is our goal,” she cuffs, a BMI monitor and a scale. The company reimburses said. “We think that this will increase our employees’ effi- employees for the cost of running in local races, and provides ciency, and their energy for their jobs.” support to local charitable athletic events, such as a 5K race in Poolesville and an all-night relay race to raise money to help Kalantzis also said that the program, which is called “Your those who have cancer. Last year, the company held two events Wellness Counts,” makes her company more attractive to po- involving physical activity: employees dug trenches to help install tential employees. The IT industry is growing, and as a result, rain barrels at a farm a few miles from company headquarters, companies are competing vigorously for top workers. “We’re and played laser tag and other games at an amusement park. all trying to recruit the same employees,” she said. “I’m a big believer in branding, and wellness is a great way to differenti- CNS also encourages employees to take advantage of the pre- ate our company from others. It’s just another good reason ventive features of their health insurance. For instance, the to work here.” She said that some employees have told her company’s provider offers an online assessment to help mem- that the wellness program was a major reason they chose bers analyze their health status. CNS when they had more than one job offer. CNS computer engineer Damien Ancruem said CNS’ wellness In 2010, CNS began having regular “lunch and learn” wellness program has made a difference in his life. He said he realized sessions; employees gather in a conference room at the compa- that he needed to watch his cholesterol and exercise more. ny’s headquarters in Poolesville, Maryland to hear speakers on a Since taking the survey, he has begun to take long walks with range of topics, including yoga, women’s health and stretching at his wife, and plays more on weekends with his highly energetic work. Last year, Kalantzis brought in an expert from an organic 6-year-old son. “They’re definitely more concerned about your market to talk about how certain foods have especially healthy wellbeing than other companies I’ve worked for,” he said. “That characteristics. The sessions are videotaped and webcast, so makes a big difference. They honestly care about your health.” that workers in Florida and Ft. Detrick, Maryland (where many CNS employees are now based) can also take part. 82 3. Examples of Faith-Based Organizations Supporting Health One area of focus for Let’s Move! is neighbor- n rganize a Wellness Council. O hood and faith-based organizations. Let’s Move! suggests several “Ideas for Action,” Let’s Move Faith and Communities includes support- such as hosting nutrition education classes, ing “Wellness Leadership,” which asks leaders to: using church or other neighborhood grounds to grow healthy food and incorporating exer- n stablish wellness as a priority for their or- E cise into weekly activities. The following are five ganization and provide leadership through examples of health-focused, faith-based preven- consistent messaging; tion and wellness initiatives. n dentify a Wellness Ambassador and direct I that person to create and lead a Wellness Council or Ministry; and First African Methodist Episcopal Church: Reducing Health Dis- parities through Education and Empowerment First African Methodist Episcopal (FAME) for and commitment to the benefits of healthy Church, the oldest church founded by African eating and physical activity. Americans in Los Angeles, California, with a Offered free-of-charge, residents complete a congregation of more than 19,000 members, 6-week Champion Empowerment Program in is working to improve health outcomes and order to serve as healthy lifestyle ambassadors reduce health disparities for the communities it and change agents in their community. Ambas- serves. Through FAME Assistance Corporation, sadors help plan and execute complimentary its community and economic development arm, community health fairs and healthy living classes. FAME is inspiring Californians to make healthier The curriculum encompasses nutrition, healthy choices every day. cooking, physical activity/exercise, presentation FAME has created several programs and initia- skills, entrepreneurship, community advocacy, tives to increase awareness of the crisis of pre- and the link between diet and disease. With ventable diseases that disproportionately affects funding provided by the Network for a Healthy low-income and ethnic minority communities, California, Kaiser Permanente and the UCLA as well as educate and empower individuals to Center for Health Equity, FAME impacts thou- make healthy choices where they live, work, sands of individuals. learn, play and worship. Where We Shop To connect widely and impact the greatest number of people throughout Los Angeles and Every Saturday and Sunday, FAME transforms its California, FAME’s outreach extends beyond parking lot into a produce market where con- its immediate congregation and neighborhood. gregants and community members can purchase Through a broad coalition of community part- fresh and affordable produce. The market helps ners, including a multi-denominational network people gain access to healthy foods, promotes of churches, energized leaders and complimen- fruit and vegetable consumption, and showcases tary agencies, FAME reaches the underserved FAME’s health programs. and is committed to creating healthy individuals, In March 2012, in association with Mayor An- families and neighborhoods. FAME’s approach is tonio Villaraigosa’s Good Food Day LA, FAME to work both with individuals and within existing delivered “Healthy Heritage,” a cooking dem- institutions to create new environments that will onstration and food sampling featuring chefs lead to a lifetime of better health. preparing ethnic foods in a healthier way. Chefs demonstrated how to make healthy tweaks to Where We Live traditional African American, Latino and Korean Partnering with the Housing Authority of the favorites to show families how to improve nutri- City of Los Angeles, FAME offers a series of tion without compromising flavor. Food samples training programs and community events at local were provided for all to enjoy. public housing projects to create appreciation 83 Where We Learn system. During the program, parents and chil- When First Lady Michelle Obama started Let’s dren receive instruction on many Olympic Sports Move! to reverse the epidemic of childhood obe- and information on where to obtain non-profit sity in one generation, FAME responded to the resources and support. In addition, thousands call to action by launching Let’s Move L.A.!. Over of parents learn how to enroll their children in the last two years, FAME has facilitated the dis- community athletic programs and how to help semination of nutrition education materials and their families practice a healthy lifestyle.   led physical activities at schools and community events focused on creating healthier environ- Where We Worship ments for children and instilling healthy habits A core audience for FAME’s programs and mes- that last a lifetime. sage is its broad-based network of churches. Begun at home and now expanded throughout In May 2012, FAME further engaged young Southern California, FAME is dedicated to mak- people with the Let’s Move Youth Summit. The ing church a place of physical as well as spiritual Youth Summit encouraged young people to take well-being. charge of their health, set and achieve fitness goals, and become leaders in their community The Body&Soul collaborative brings a series of that advocate for better health. initiatives and programs to local churches that in- clude health messaging from the pulpit; monthly Where We Play newsletters; food policies; healthy cooking and An outgrowth of Let’s Move L.A.!, FAME launched exercise classes; community health fairs; and an Let’s Move California! in June 2012 with a series exercise break during worship services. of events aimed at uniting and invigorating Cali- In partnership with the University of California, fornians to eat healthier and be more active. Let’s Los Angeles, with support from the Centers Move California! will create a statewide frame- for Disease Control and Prevention, FAME work to educate citizens, streamline access to created an Instant Recess® video — designed healthy lifestyle resources, and provide training to get people to take 10-minute physical activ- to incorporate Let’s Move California! program- ity breaks. Instant Recess has been adopted by ming into existing infrastructure. congregations all over the city with plans for Central to the Let’s Move California! launch is national distribution through Let’s Move! Faith Fitness Feria, a one-day intensive program to in- and Communities. The video, which has a spiri- troduce children and parents to the “movement tual and gospel flair, provides churches with fun ABCs,” a fundamental step in early childhood de- and active ways to spend 10 minutes exercising velopment that enables participation and success while worshiping, specifically during children’s in athletics. Families participated in more than 40 Sunday School, Sunday worship service, choir sports and fitness-related activities, and learned rehearsal, special events and celebrations, and how to engage more fully in the U.S. athletic Bible study meetings. 84 H.O.P.E. Initiative and the National Baptist Convention The National Baptist Convention USA (NBCUSA), church in Mississippi resisted the change initially incorporated through its Congress of Christian Ed- but eventually made the switch thanks to the ucation, is committed to ensuring all National Bap- leadership of their pastor. tist churches have health and wellness ministries. A Dr. Michael Minor, a special health assistant to major component is the NBC Health Outreach the president of the National Baptist Congress, and Prevention Education (H.O.P.E.) Initiative, said the idea of the no fry zone was a way to which is a partnership among churches, medi- get his foot in the door, talk about health and cal professionals and public health organizations. wellness and demonstrate how the church H.O.P.E. adopted the “Mississippi Model” for faith- could take a stand. He viewed the fry ban as based health and wellness mobilization championed similar to when churches stopped using wine for by an association of NBCUSA church Usher Fed- communion to help congregants with alcohol eration (UF) ministries in Northwest Mississippi. issues. “We are trying to work with people who Through H.O.P.E., the NBCUSA reaches out across have health challenges and keep others from their denomination to educate and inspire Baptists having those challenges,” Dr. Minor said. to commit to healthier lifestyles through health and wellness education; referral sources and collateral Using Church and Community Grounds to material; and facilitators and resource persons. Benefit Health and Wellness The framework of the H.O.P.E. Initiative began The Church and Community Garden Project pro- in Northwest Mississippi in the late 1990s. As motes the development of gardens to increase ac- NBCUSA churches worked to include health and cess to and consumption of fruits and vegetables. It wellness in worship, they found that, while peo- has the added bonus of helping congregants become ple liked the idea of improving health, they didn’t physically active through gardening and allowing for know what to do. So, in 2002, the UF created a shared use of the land for exercise and play. health and wellness observers calendar. Pulling In addition, some congregants wanted to walk information from Healthy People 2000 and other around church grounds, so ministers have been public health research organizations, the calendar encouraged to measure off distances so congre- was fashioned to include monthly observances. gants can track how far they are walking. Some It worked fairly well the first year, but usage ministers have gone so far as to create paths link- took off in the second year. In the second itera- ing churches, grounds and cemeteries to ensure tion of the calendar, they added more options congregants have safe places to walk and exercise. and ways for people to make healthy choices. “The bottom line is we need to spend more Next, the UF created a companion guide to go time focused on reaching a common ground and along with the calendar. Both pieces provide making lives better,” said Dr. Minor. “We can all easy-to-understand tips on how to incorporate rally around health to make our community bet- health into worship and daily lives. For example, ter. Who wouldn’t want a healthier nation?” September includes Sickle Cell Sabbath and No- vember includes Diabetes ID (I Decide) Day. Health Ambassadors The signature event of the calendar and guide After the NBC published the calendar and the is Taste Test Sunday, focused on diabetic safe guide, congregants began exploring ways to bene- desserts. The event includes a blind taste test of fit their communities as a whole. That sparked the desserts made with and without sugar. Organiz- creation of health ambassadors, representatives of ers found that men in the congregation couldn’t each church that are trained as health promoters. tell the difference and even preferred the diabetic In addition, the NBC created the “First Ladies for safe desserts. In the past year, other diabetic safe the First Lady,” a group of local church first ladies foods have been to the taste test and have proved advocating on behalf of Let’s Move!. To mark the popular. Along with the calendar and guide, the two-year anniversary of Let’s Move!, First Lady NBC created the What’s Cooking? Initiative with Michelle Obama spoke at Northland Church in the American Diabetes Association aimed at pro- Longwood, Florida and asked the National Baptist moting healthy ingredients in meals. Convention to train and deploy 10,000 health ambassadors in 10,000 churches by September No Fry Zones 2012. By the end of April, 2012, NBCUSA state In addition, some Baptist churches have cre- and district affiliates representing more than 3,000 ated “no fry” zones in their congregations. One churches have committed to this training. 85 The Jewish Community Center Association’s Discover: CATCH Early Childhood Program To tackle obesity, the Jewish Community Cen- foods with their children and asking schools to ter (JCC) Association focused on one simple serve healthier foods. Encouraged by these re- premise: it’s much easier to create good sults, JCC Association added an education piece health habits than it is to change bad ones. on farming and farm-to-table initiatives. JCCs consider health and wellness inherent to In November 2010, JCC Association started their tradition and cultural values; staying healthy “JCC Grows”  to encourage JCCs to establish and taking care of their bodies is an aspect of gardens and encourage members to support respecting their faith, making healthy living part fresh food projects and be physically active. A of their heritage. significant portion of the harvests from the gar- dens are donated to local food pantries.  Three years ago, the JCC Association partnered with the University of Texas School of Public The JCC Movement also has one of the largest net- Health and its Coordinated Approach to Child works of day and resident camps in North America. Health (CATCH) Program. Together, they cre- Since starting their partnership with Discover: ated Discover: CATCH Early Childhood, a child CATCH, camps have gotten rid of the old “bug juice wellness program aimed at encouraging healthy and greasy grilled cheese” in favor of healthier food, habits in the youngest members of the commu- some of which comes from their own gardens. nity and their families. Health and Wellness at Local JCCs JCC Association’s version of Discover: CATCH is based on a foundation of Jewish values. The evi- The Shaw Jewish Community Center in dence-based model that CATCH has pioneered Akron, Ohio held a Discover: CATCH Well- attempts to instill an appreciation for physical ness Fair on January 22, 2012. More than 1,000 activity in children ages 3 to 5 and encourages people took part and learned about all different them to develop life-long healthy eating habits. aspects of health and wellness. As part of the program, children learn to have Discover: CATCH was a natural complement fun while exercising. They are also taught to dif- to the Shaw JCC’s Ethical Start Early Child- ferentiate between “go” foods, which are good hood Program. According to Lisa Pesantez, for them and “whoa” foods that are less healthy. who teaches a group of two-year olds and a The program is focused on young children, but it class of third-, fourth- and fifth-graders, “For seeks to engage the adults in their lives, including my [two-year olds] I think the biggest thing has parents and educators. The JCC Association has been showing them that exercising can be fun! I created a series of parent tip sheets to bring les- believe that the purpose is to give wholeness and sons home and help the entire family think more completeness to physical activity, spirituality, and carefully about food, nutrition and exercise. The nutrition for both the students and the teachers.” model positions JCCs as a wellness provider to the The Asheville Jewish Community Center in community. JCCs have been able to reach families North Carolina took the JCC Grows initiative and with older children as well by incorporating Dis- created an entire Jewish Children’s Garden Cur- cover: CATCH into teen after-school programs. riculum. They started by forming a volunteer com- While the Discover: CATCH program is just mittee of parents and interested teaching staff with finishing the final stages of the pilot phase, the garden design, art therapy and Judaic experience. responses across the board have been positive. The Asheville JCC is in a busy downtown area Based on surveys sent to members before and with just two narrow grassy areas (one 20’ x after the program began, there has been a cultural 70’ and the other 20’ x 25’) which became their shift in the way early childhood classes are being children’s garden. The community helped fund taught. For instance, young children no longer play the garden through a Children’s Garden Legacy “elimination games” (such as Duck, Duck, Goose) Campaign, which offered naming opportunities where a large portion of children are not partici- for each section. The JCC also solicited volunteers pating at any given time. Children are also growing to help build the garden, including a teen youth their own fruits and vegetables for snacks. group, preschool teachers, parents, landscapers, The pilot communities are also seeing a change gardeners, and many others. The garden provides in how early childhood educators and staff work healthy foods for the entire community and edu- with parents. Parents are sending healthier cational opportunities for children. 86 Adventists InStep for Life – the Seventh-day Adventist Church To help families address the obesity epidemic, the North on nutrition health curriculum. The 22 students at Cleburne American Division of the Seventh-day Adventist (SDA) Church Adventist Christian School, located in Cleburne, Texas created Adventists InStep for Life, which forms partnerships run one mile every day, and then play sports or participate in between churches, schools and the public health community other activities for at least an hour a day. Students accumulate to reduce childhood obesity and inspire healthy eating along credits and can earn rewards for their participation. with physical activity. The Filipino Capital SDA Church in Beltsville, Maryland, has They have set four goals centered on increasing physical focused on helping children understand what a healthy lifestyle activity and the consumption of fruit and vegetables: means. Once a month, they host a healthy eating potluck fea- turing mainly vegetarian dishes. In addition, the SDA hosts quar- 1. Accumulating 2 million physical activity miles through walk- terly cooking demos that make the preparation of healthy foods ing, biking, swimming, running and other physical activities; fun. Going beyond food, the SDA promotes an “In Step for 2. aving 60 percent of Adventist students achieve Individual Ac- H Life” program; on the last Sunday of every month, congregants tive Lifestyle awards by either qualifying for the the Presidential wear pedometers to count their total steps when walking. Active Lifestyle Award, which  requires participants to commit In the Washington, D.C. Metro Area, the Emmanuel Brin- to physical activity five days a week for six weeks, or the NAD klow Church recently organized a presentation from an Iron- Active Lifestyle Award, which rewards people for reaching man competitor during the “Health Minute” segment of their mile milestones ranging from 100 miles of exercise to 2,000; worship. In addition, Brinklow created a fitness class under 3. aunching 100 summer feeding sites, which provide nutri- L the direction of a personal trainer. The class was so successful tious summer meals to children who rely on the National that they now hold another class twice weekly for the entire School Breakfast and Lunch Programs; and community. The church also utilizes nearby Brinklow Walk- ing Trail, which wraps around 30 acres that will eventually 4. Starting 100 vegetable gardens or farmers’ markets. house the Emmanuel Brinklow health and fitness campus. The church has also used their land to sponsor more than 20 com- Local Ministries munity gardens and has incorporated a healthy lifestyles unit in The Allegheny East Conference Churches started their the science curriculum. “Let’s Move Day” at 4:00 a.m. with a 20 minute exercise routine followed by worship and a 32-block walk to 15th The Kettering Adventist Church in Ohio has created a and Christian Streets in South Philadelphia. Pastor Colin Health Ministry team under the guidance of their Faith Com- Brathwaite and his wife, Jeannie, joined the West Philadelphia munity Nurse, Mel Miller. The team is planning a Community members on the entire walk. While members were given bus Garden project, during which church members will be en- tokens to ride back to the West Philadelphia Church, they couraged to bring garden produce that will be delivered to were so excited about completing the initial walk to south the McKinley United Methodist Church (UMC) in downtown Philadelphia that they decided to walk back. In total, they Dayton, Ohio. In addition, they will set up a farmers’ market hiked more than seven miles. In Texas, Killeen SDA Church, to sell fresh produce for a small fee, with all proceeds from which is close to Fort Hood, the largest military base in the the market being donated to the McKinley UMC. United States, planned their event in just three weeks but got Palm Harbor SDA Church in Florida recently challenged nearly 80 people to complete their 5K run/walk. its members to participate in a half marathon or five-kilometer Orlando Junior Academy (OJA), in Orlando, Florida, has race. Participants could run or walk with proceeds going to begun to focus on getting students “in step for life.”  All pre-K the Childhood Obesity Foundation. “My first 5k was a great through eighth-grade students participate in a school garden experience,” said one participant. “When our Pastor first an- that won first place in the 2011 Florida School Garden Com- nounced the 5k event and explained that it was a three mile petition. In addition, OJA has created healthy eating experi- walk, I said there is no way I could walk three miles.  But the ences for students through partnerships with a local chef, next week when it was mentioned again, I decided I would try dietitian and nutritionist. Together, the educators provide it.  So at age 80, I started practice for the three mile walk…I healthy vegetarian food, a cooking class elective and a hands- was able to complete the event.  Now I am looking forward to another marathon.” 87 AmpleHarvest.org Many Americans lack access to fresh and affordable n Registered nearly 5,100 food pantries; fruits and vegetables. At the same time, there are n n 2011, helped growers donate more than 21 I more than 40 million Americans who grow food million pounds of freshly harvested produce; and and often can’t use everything they grow. Ample- Harvest.org was created to connect those growers n Helped millions of pantry clients feed their with those who need the food the most. Since families fresh food. 2009, AmpleHarvet.org has connected thousands Gary Oppenheimer, AmpleHarvest.org founder of home gardens with more than 5,000 registered and executive director, “urges communities to local food pantries—70 percent of which are run engage their policy-makers in getting local sourced by faith-based organizations—across all 50 states. foods to those in need.” AmpleHarvet.org didn’t create anything new, per AmpleHarvest.org connects growers with pan- se, but connected the dots between those who tries to ensure those without fresh food gain wanted to and could donate and those who need access. “We are trying to change the system of fresh foods. The donations help food pantries save how people are getting healthy food. Once a money and invest in other necessities. Ample- grower starts, he will donate food for the rest of Harvet.org enables anyone to be a philanthropist: his gardening life. Working with growers and food with a $2 pack of seed, someone can grow $50 pantries has created a permanent sustainable solu- worth of food and donate what they don’t need. tion,” said Oppenheimer. “Please visit www.Am- At no cost to donors, pantries or taxpayers, Am- pleHarvest.org/waystohelp to learn how you can pleHarvest.org has: help AmpleHarvest.org help your community.” 4. Examples of Improving Nutrition and Physical Activity in Schools Nearly 23 million children and teens in the to achieve its goal of reducing the prevalence of United States are considered overweight or childhood obesity by 2015.  obese—a problem that is exacerbated when While the USDA works to create a common set junk food and sugary drinks are sold in schools. of improved nutrition standards for “competi- The Alliance for a Healthier Generation, which tive foods” (all foods and beverages available provided the following examples of how some outside of school meals, such as those sold in schools have focused on improving the quality vending machines, cafeteria à la carte lines of food and drinks they serve, is a non-profit and school stores), many schools have already organization founded by the American Heart started replacing unhealthy items with more nu- Association and William J. Clinton Foundation. tritious choices on their own. As the examples For the past seven years, the Alliance has worked below show, students are responding positively with families, schools, doctors, and communities by purchasing and eating healthier foods. Healthy Schools Program Interim Evaluation Shows Progress The Healthy Schools Program, created by the Alli- beverages, health education, physical education, ance for a Healthier Generation and receives major physical activity outside of physical education, funding from RWJF. It is the largest program in the before- and after-school programs and school nation focusing on school-based obesity prevention. employee wellness. Results of the interim study The program targets schools with predominantly show that schools made significant changes in all low-income and minority students. In an effort to content areas.317 The most significant improve- evaluate the effectiveness of the program, research- ments were made to school employee wellness ers conducted an interim study to measure the and school meals, with the least amount of prog- progress of schools that enrolled in the program in ress in physical education, policies and systems, 2007-2008 and 2008-2009 school years. and before- and after-school programs.318 The Healthy Schools Program provides training The more training and technical assistance a school and technical assistance at no-cost to schools for received, the more progress it made in improving four years in eight content areas: policies and health policies, practices and environments.319 systems, school meals, competitive foods and 88 DeLong Middle School, Eau Claire, Wisconsin Student Population: 895 Thanks to the Wellness Warriors’ latest efforts, DeLong no lon- Student Demographics: 41% eligible for free or reduced-price ger sells junk food in vending machines, at concessions stands, lunch; 81% white; 11% Asian, 4% Black or at the school store. The school now offers healthier options, such as pretzels, granola bars, water and small bottles of 100% School Snapshot juice. Students also have started a vegetable garden, held health Five years ago, a curious student at DeLong Middle School and wellness fairs, and encouraged their teachers and parents to asked his science teacher why the apple he ate for lunch was follow their example. “Delong Middle School students are very grown in Washington, not Wisconsin. In addition to raising the proud to go to a school where healthy habits are encouraged school’s awareness about the source of foods, this question and healthy choices are available,” said Brettingen. sparked a movement to improve the health and nutrition poli- Wisconsin Snapshot cies for all DeLong students. That science teacher, Mikki Bret- tingen, was inspired to create and advise the Wellness Warriors, In Wisconsin, 31 schools participate in the Healthy Schools a group of students committed to healthy eating and active liv- Program. In 2011, two schools from the state received a ing. While the group got their start getting the cafeteria to serve national-level award from the Alliance for a Healthier Genera- locally grown apples, their focus has evolved and expanded. tion for their efforts to make their campuses healthier. Rio Hondo Elementary School, Arcadia, California Student Population: 850 other healthy toppings to spruce up the salad, Bettger put a call in Student Demographics: 81% eligible for free or reduced-price to the nutrition director and the very next day, they found dried lunch; 67% Hispanic; 21% Asian fruits, nuts and even more choices of salad dressing. Other school efforts include a weekly delivery of fresh fruits and vegetables, and School Snapshot a new initiative designed to increase physical activity called “P.E. Since joining the Healthy Schools Program, Rio Hondo Elementary Buddies”. The program, started with the help of one of Rio Hon- School has made a lot of changes in the à la carte foods offered do’s P.E. teachers, partners the younger primary school students during breakfast and lunch. Gone is the chocolate milk, junk foods with older, middle school student mentors who give them help and sugary beverages. Instead, students have only bottled water and inspiration as they do all the activities during their P.E classes. in the vending machines and healthy options in the cafeteria, California Snapshot including a large, fresh salad bar that includes lots of fruits and vegetables, and even pre-portioned salad dressing. Brian Bettger, In California, more than 500 schools participate in the Healthy Rio Hondo’s principal, said the district’s Food and Nutrition De- Schools Program. In 2011, 14 schools from the state, including partment is very responsive and works closely with the school to two in the El Monte School District, received a national-level ensure everything meets the nutritional guidelines. In fact, after award from the Alliance for a Healthier Generation for their ef- receiving a note from a student asking for more seeds, raisins, and forts to make their campuses healthier. Lewis Frasier Middle School, Hinesville, Georgia Student Population: 815 as water and 100 percent juice, have sold just as well and have Student Demographics: 66% eligible for free or reduced-price not impacted the profitability of the vending machines or store. lunch; 62% Black; 27% white; 8% Hispanic Other school efforts include a 50-day Health Challenge, which uses the USDA’s Choose My Plate website to motivate staff School Snapshot to earn points for exercising and staying within their recom- Lewis Frasier Middle School’s Healthy Schools Program initia- mended daily calorie range. Because teachers and staff to serve tive has an enthusiastic leader in Peggy Rayman, the school as role models for the students, the program encourages the nurse, who has enjoyed support from both the prior and cur- entire school to get involved to create a healthy environment. rent school principal. Lewis Fraiser has increased the selection of fresh fruits and vegetables that students receive in the caf- Georgia Snapshot eteria. The school has also worked with vendors to make sure In Georgia, nearly 300 schools participate in the Healthy that beverages sold in vending machines are compliant with Schools Program. In 2011, 17 schools from the state received the Alliance’s School Beverage Guidelines. According to Ray- a national-level award from the Alliance for a Healthier Gen- man, the school is encouraged that the healthier options, such eration for their efforts to make their campuses healthier. 89 Loring Community School, Minneapolis, Minnesota Student Population: 435 activity, the school moved recess up in the schedule—before Student Demographics: 69% eligible for free or reduced-price lunch, which encourages students to eat more of their lunch lunch; 44% Black; 25% White; 17% Hispanic and return to the classroom calmer and ready to learn. The school also encourages teachers to offer academic movement School Snapshot games during which students move while they learn and have Loring Community School has cultivated a garden and offers a chance to release some energy. organic cooking classes to students. The school also has an Minnesota Snapshot active health wellness council that includes students. Some of the council’s efforts include encouraging students to carry In Minnesota, more than 65 schools participate in the Healthy water bottles and mentoring younger students in the school Schools Program. In 2011, four schools from the state, includ- garden. In addition, the school has made an effort to ensure ing Loring Community School, received a national-level award their students have opportunities to be more active during from the Alliance for a Healthier Generation for their efforts the school day. In order to increase opportunities for physical to make their campuses healthier. Lotts Creek Community School, Hazard, Kentucky Student Population: 240 options. “Many parents have told me how much they appreci- Student Demographics: 71% eligible for free or reduced-price ated the switch,” said Whitaker. lunch In addition to school events like wellness fairs and field days, and a staff weight- loss competition, which netted 676 pounds School Snapshot lost among participants in 2011, the school recently hired a Lotts Creek Community School’s commitment to healthy eat- second physical education teacher to provide more exercise ing and physical activity is evident everywhere on campus. In opportunities for students. The school even makes its state- the cafeteria à la carte line, students can now purchase fruits of-the-art fitness center available to the public free of charge. and yogurt, and the school vending machines are stocked with foods, such as cereal and granola bars, that adhere to the Alli- Kentucky Snapshot ance’s Competitive Foods Guidelines. According to the school In Kentucky, 100 schools participate in the Healthy Schools director, Alice Whitaker, Lotts Creek families are proud Program. In 2011, five schools from the state received a that the school eliminated food-based fundraisers. Instead national-level award from the Alliance for a Healthier Genera- of doughnuts, kitchen knives are now one of the fundraising tion for their efforts to make their campuses healthier. Seaman High School, Topeka Kansas Student Population: 1,158 determined to follow through because we want to create an Student Demographics: 27% eligible for free or reduced-price environment that reinforces healthy lifestyle choices at school lunch; 93% White; 2% Black; 2% Hispanic and at home,” said Welch. Seaman High School also has established Wellness Wednesdays School Snapshot and Fitness Fridays, activities that are designed to incorporate Seaman High School created a healthier environment for stu- nutrition and fitness information into the school day. Students and dents by offering fresh fruit during breakfast and lunch, as well as educators at Seaman High School are committed to promoting à la carte items and meals that are prepared with lower-calorie, healthy behaviors and lifestyle choices through ongoing education. lower-fat ingredients. In addition, the school is working to en- sure that drinks sold in vending machines on campus adhere to Kansas Snapshot the Alliance’s School Beverage Guidelines. According to Claudia In Kansas, more than 60 schools participate in the Healthy Welch, a P.E. teacher at Seaman High School, adjusting the Schools Program. In 2011, three schools from the state re- selection available in vending machines has been challenging ceived a national-level award from the Alliance for a Healthier because it involves changing the vending contract. “We’re Generation for their efforts to make their campuses healthier. 90 John M. Sexton Elementary School, St. Petersburg, Florida Student Population: 718 the produce. So far, she has dressed up as a green bean queen, Student Demographics: 71% eligible for free or reduced-price purple sweet potato punk rocker, and a pomegranate princess. lunch; 57% White; 23% Black; 11% Asian; 7% Hispanic Other school efforts have included successfully replacing food- based fundraisers with healthy, earth friendly alternatives like School Snapshot “Grow Your Own Garden” kits. John M. Sexton Elementary The à la carte options at John M. Sexton Elementary School also helped encourage students to be more active by imple- used to include sugary beverages and ice cream. This year, menting a Walking School Bus program before and after school. the options include low-fat yogurt, 100 percent frozen fruit popsicles, granola bars and trail mix instead. According to Beth Florida Snapshot Bates, the cafeteria’s food service director, the switch was well In Florida, more than 200 schools serving 180,000 students partici- received by students, and the new products sold so well that pate in the Healthy Schools Program. In 2011, 46 schools from the the cafeteria made a profit. Moreover, Bates now feels so en- state, including John M. Sexton Elementary, received a national- thusiastic about increasing the availability of healthier à la carte level award from the Alliance for a Healthier Generation for their options in the cafeteria line that each time the school intro- efforts to make their campuses healthier. Notably, 40 of 46 cel- duces a new fruit or vegetable, she dresses up to help promote ebrated schools from Florida were from Miami-Dade County. Southeast Polk High School, Pleasant Hill, Iowa Student Population: 1,731 junk foods. According to Dietzenbach, replacing unhealthy op- Student Demographics: 27% eligible for free or reduced-price tions with healthier ones still yielded profits for the school. lunch; 93% White; 3% Hispanic Other major accomplishments included expanding the school’s breakfast program, which now offers every student the option School Snapshot of a healthy breakfast, enhancing school fitness facilities, and Last year, Glenn Dietzenbach, as former principal of Southeast eliminating food-based parties as a classroom reward. Polk Junior High School, worked closely with the previous food services director to make sure that all foods served in the caf- Iowa Snapshot eteria à la carte line and vending machines complied with the In Iowa, nearly 60 schools participate in the Healthy Schools Alliance’s guidelines for competitive foods in K-12 schools. Stu- Program. In 2011, four schools from the state, including dents are now able to purchase healthier snacks, such as pop- Southeast Polk Junior High School, received a national-level corn and granola bars, instead of chips and cookies. In addition, award from the Alliance for a Healthier Generation for their the school eliminated soda machines and concessions featuring efforts to make their campuses healthier. Southside Middle School, Florence, South Carolina Student Population: 821 program before school and during lunch, and various fitness Student Demographics: 59% eligible for free or reduced-price programs - such as a dance club and participation in Fuel Up to lunch; 49% Black; 48% White Play 60. Southside also promotes physical activity by broadcast- ing a “Jamming Minute” produced by students every Friday. School Snapshot South Carolina Snapshot The vending machines at Southside Middle School used to offer only sugary beverages. This year, there are healthier, lower- In South Carolina, more than 100 schools serving nearly calorie options, such as water and 100 percent fruit juice. 60,000 students participate in the Healthy Schools Program. And, in the cafeteria, the food service director now offers an In 2011, only three schools from the state including Southside additional fruit or vegetable option during lunch and only uses Middle School received a national-level award from the Alli- unsaturated fat cooking oil to prepare meals. Other school ef- ance for a Healthier Generation for their efforts to make their forts have included the creation of a school garden, a walking campuses healthier. 91 West Bolivar Middle School, Rosedale, Mississippi Student Population: 298 West Bolivar has been able to focus on physical activity as Student demographics: 96% eligible for free or reduced-price well. The students have physical education every day and a lunch; 96% Black; 4% White new track at the school has inspired kids to walk a mile a day. The recent improvements also have motivated many teachers School Snapshot to exercise regularly and eat healthier foods. The school dis- With the high obesity rates in Mississippi, students and staff trict now holds monthly breakfasts to inform the community at West Bolivar Middle School knew they needed to make of the healthy changes taking place on campus and to ask for improvements. Glenda Atkins, the school counselor, helped input on other issues to tackle. coordinate a variety of efforts including: removing soda from Mississippi Snapshot the vending machines and adding water; changing cooking techniques in the cafeteria—more baking instead of frying; According to the National Survey of Children’s Health, and asking parents to comply with school wellness guidelines Mississippi has the highest childhood obesity rate in the when they send in foods for celebrations. In addition, every nation—44.4 percent. Currently, more than 100 schools in the classroom now receives a healthy afternoon snack—typically state participate in the Healthy Schools Program, and in 2011 a basket of fruits or vegetables, such as kiwis, melons, carrots one school from the state (Lyon Elementary School) received or cucumbers. “Students enjoy the healthy snacks and the bas- a national level award from the Alliance for a Healthier kets are usually empty by the end of period.” said Atkins. Generation for its efforts to make its campus healthier. Additional Alliance for a Healthier Generation Stories: Staff Wellness Successes n At CTA Goodman Elementary School in Chandler, Ari- physical activity, healthy eating, stress management and zona320 the staff started an Employee Wellness Boot Camp reduction of tobacco use among employees. More than program. Administrators hoped that the staff would be able 500 employees and their family members have already to lead by example through adopting healthy behaviors. The enrolled in the “Step into Wellness Pedometer Program.” PE teacher leads the staff Boot Camp twice a week for all em- The district is also conducting a health risk assessment and ployees. At first there was limited participation, but interest in employees who participate receive a $50 gift certificate and the class expanded beyond the athletic department to include reduced health insurance premium. many cafeteria workers as well. Staff wellness programs have n Administrators at Carson High School in Carson City, expanded to include “Gator Wellness,” which is a bulletin Nevada323 meet as a school wellness council to come up board in the cafeteria that has healthy recipes and ideas on with attainable health goals for the school. One year after how to be healthy. The school also has plans to plant a garden setting up the wellness council, employees participate in a with the hopes of supplementing their lunch program, as well variety of activities, including weekend hikes, yoga, spin and as providing fresh produce to community families in need. other fitness classes, and the school encourages employees n In Charlotte, North Carolina the teacher-parent to join their bike-to-work contest. In the fall, the school basketball game at Idlewild Elementary School has plans to begin offering a low-fat cooking class for employ- become a popular tradition.321 In an effort to increase ees to take advantage of before the holidays, and they will opportunities for staff wellness as well as have a healthy add another fitness course called “Drums Alive,” which fundraiser, the elementary school decided to host a combines aerobics, drumming and dance. teacher-parent basketball game. The game was such a suc- n ealthy competition is supported at Woodstock H cess the school plans to hold another game, which will also School District in Woodstock, Illinois.324 The school include a student tournament. Not only did they have fun district has hosted a health fair for district employees, con- while being physically active, the school also raised $800 ducted employee wellness surveys and created the “Main- from healthy snacks and beverages they sold at the game. tain Don’t Gain Holiday Challenge.” They started the school The school plans to use the money they raised to purchase year with a physical activity challenge for staff; putting to- additional PE and recess equipment. gether teams and having participants log all their physical ac- n Eau Claire Area School District in Wisconsin322 re- tivity online. During the 12-week program, the most active cently launched a district-wide employee wellness program. team was awarded a golden foot trophy every two weeks. The district hired two wellness coordinators to focus on 92 Spotlight on School Nurses and Strategies to Reduce Childhood Obesity The National Association of School Nurses (NASN) The project emphasizes an innovative approach, recognizes that school nurses are in important posi- stressing the importance of creating collabora- tions to impact the childhood obesity epidemic, tions beyond the school from the outset as well reach ethnically diverse children and provide for as having wellness coordinators to help manage better care and outcomes for students.325 School the programs. Collaborations have included a nurses are uniquely able to care for children and wide range of partners, including home improve- teens who are overweight and obese, especially by ment stores, churches, other school clubs, col- accessing community resources and collaborating lege extension services, parks and recreation, with the health care community.326 school food services, Parent Teacher Associa- tions, a dairy council, county health departments, The NASN recently partnered with the United the chamber of commerce, grocery stores, Health Foundation (UHF) to undertake an inno- local restaurants, and even a photographer who vative school health model to address the child- helped create a photo journal of the project. hood obesity epidemic, which was first piloted in 2011 in six sites in Texas, Georgia and Florida. Some of the projects included: Key components of this model included an edu- n mprovements to a 2.1 mile designated trail con- I cational session for school nurses about evidence- necting three schools, including better marking based practices, advocacy and leadership skills; on the existing path and new fitness stations; wellness coordinators in each site; strategies to n A walking club for all grades during recess engage families, stakeholders, and the community times chaperoned by a teacher and a jump at large; and awarding micro-grants to school rope club for upper grades; nurses for school-based programs addressing childhood overweight and obesity issues. n Every day physical activities using Chinese jump ropes, hula-hoops, recess videos, kick balls, and resistance bands; “Great support and participation from n Playground equipment and fitness field with portable drinking fountains; the local community and the parents. n Vegetable and fruit gardens, portions of which School staff and school nurses have were then served in the cafeteria; also recognized the relationship among n Jogging and walking during “Wellness health, physical activity and academic Wednesdays”; achievement.” n hoosing Healthy Habits Student Planners; and C –School Nurse Participant n Health Fairs. School nurse administrators and wellness co- “I’m just so excited ordinators were charged with facilitating and about this. The high coordinating the childhood obesity program in each school district to promote program school and elementary engagement, engage school nurses, provide teachers met with high wellness classes to the local community and link school and elementary school students, program services to participating families. The school nurses acted as wellness resources to the parents, a nutrition professor and superintendent, district leadership, school staff, master gardeners to discuss the garden.” educators and local community leadership, all of –School Nurse Participant which help sustain programming at the school. To receive the micro-grants, school nurses submitted proposals and budgets to NASN, which received, NASN and UHF are planning to continue the evaluated and disseminated the awards to each site. A project and underscore that the most sustained total of $60,000 was available to fund proposals, with programs included strong relationships with the average micro-grant totaling $2,500. partners, consistency and persistence. 93 Conclusions and Recommendations O besity rates have grown dramatically over the past 15 to 20 years and are on track to grow significantly more in the next 20 years. 4 Section The modeling study in this report shows what’s at a relatively flat and insufficient level for years. at stake. The potential rise in obesity-related The budget for CDC has decreased from a high diseases and health care costs is stunning. The of $6.62 billion in 2005 to $6.12 billion in 2011.327 study also demonstrates the return we could see Forty states decreased their public health budgets –in terms of saving both lives and money — if we from FY 2009-10 to FY 2010-11, 30 states decreased dramatically increased the nation’s investment in budgets for a second year in a row, and 15 decreased obesity prevention. We’re at a new tipping point for a third year in a row.328 Combined state and local in the effort to prevent obesity and reverse the public health job losses total 49,310 between 2008 epidemic. Seventy-nine million Americans are and 2011.329 In addition, most federal programs pre-diabetic, and millions more are on the verge face automatic, across-the-board cuts of 8 percent of heart disease, stroke, cancer, hypertension, ar- to 10 percent in January 2013 unless Congress re- thritis and other obesity-related conditions. Bil- stores the cuts.   This could mean a cut approaching lions of health care dollars hang in the balance. $500 million to CDC; according to CDC director Thomas Friedan, such an outcome “will risk costly Unfortunately, funding for obesity prevention is and deadly spread of disease and failures to prevent heading in the wrong direction. Federal, state and tragic and expensive health problems.” 330 local public health departments have faced signifi- cant cuts in recent years that are undermining the TFAH and RWJF call on policymakers at all levels to progress being made to fight the epidemic. Even invest in obesity prevention in a way that is commen- when factoring in the Affordable Care Act’s Pre- surate with the severity of the health and financial toll vention and Public Health Fund, federal funding the epidemic takes on the nation. In addition, TFAH for public health initiatives overall, which includes and RWJF support the following policy recommen- those directed at obesity prevention, has remained dations for addressing the obesity crisis in America: A. ully Implement the Healthy, Hunger-Free Kids Act, including implementation F of school meal standards on schedule and updated Nutrition Standards for Competitive Foods In December 2010, President Obama signed the However, USDA had not yet issued required Healthy, Hunger-Free Kids Act (HHFKA) into law, rules for updated nutrition standards for: which reauthorizes child nutrition programs—in- n ompetitive foods sold outside school meal C cluding the national school lunch and breakfast programs, such as those served in à la carte programs—for the next five years. The law autho- lines, in vending machines and school stores; rized an additional $4.5 billion to provide funding for schools that meet updated nutrition standards n eals and snacks provided as part of the Child M for school meals. In January 2012, USDA finalized and Adult Care Food Program (CACFP) that updated nutrition standards for the school meals serves more than 3 million lower-income infants, programs with many of the changes being phased children and impaired or older adults. in during the 2012-2013 school year. USDA, states TFAH and RWJF recommend USDA issue a and districts must ensure that full implementation draft rule for competitive foods that would continues as scheduled and adequate training and align standards with the most current Dietary technical assistance are provided to food service oper- Guidelines for Americans and be based on rec- ators. Additional provisions in the HHFKA increased ommendations from the Institute of Medicine. the number of eligible children for school meals, The proposed rule should be released as soon strengthened school wellness policies, and provided as possible so the public can weigh in, standards training for food service workers. It also provided can be finalized and implementation can begin USDA with the authority to update nutrition stan- in schools across the country. dards for all food and beverages sold in schools. 95 B. Protect the Prevention and Public Health Fund The Prevention and Public Health Fund In 2012, Congress enacted legislation that cut (PPHF), a provision of the Affordable Care more than $5 billion from the PPHF to partially Act, is the nation’s largest single investment offset the cost of extending certain tax cuts and in prevention. The PPHF provides more than unemployment insurance, as well as the Medicare $12.5 billion in mandatory appropriations over “doc fix,” which maintains a high reimbursement the next 10 years to improve public health and rate to doctors who accept Medicare patients. Sev- prevent chronic illnesses, including obesity and eral additional attempts have been made to elimi- related diseases, through increased screenings, nate the PPHF entirely or repurpose its priorities counseling and care and community-based pre- to cover funding shortfalls in other programs. vention programs. PPHF dollars also provide Given the importance of the PPHF and its po- investments to expand and offer additional tential to transform the public health landscape, training for the public health workforce. More TFAH and RWJF recommend that the PPHF be than $2 billion has been distributed from the preserved in full, and that it not be used to off- PPHF since 2010. set or justify cuts to other programs. C. Increase Investments in Effective, Evidence-Based Obesity-Prevention Programs, Including Community Transformation Grants As the state policy tracking and stories sections Effective, evidence-based policies must be signif- of this report demonstrate, efforts in neighbor- icantly expanded and engage a wide spectrum hoods around the country are helping to make of partners to reach their full potential. healthy choices easier for millions of Ameri- For instance, Community Transformation Grants cans. Policy changes and initiatives led by Let’s (CTGs), launched in 2011 through the Afford- Move, the Alliance for a Healthier Generation, able Care Act’s Prevention and Public Health the Y of the USA and ChildObesity180 are pro- Fund, include a performance measure for all viding people with significant opportunities to funded nutrition and physical activity programs improve nutrition and increase physical activity. to reduce the rate of obesity among their target These efforts show that everyone can make a dif- populations by 5 percent. The grants require ference — from employers to places of worship communities to use evidence-based approaches to schools and out-of-school programs. and include an evaluation to ensure they meet However, our modeling shows that existing ef- measurable, achievable outcomes. In the first forts are not bending the obesity health and cost year of the program, more than 2,000 communi- curves sufficiently. We need to do more -- and do ties applied for CTGs, but there was only enough it fast — if we’re going to put our children and funding for 61. As the modeling study in the re- our country on a path to a healthier future. Our port shows, evidence-based programs like CTGs health and wealth are inextricably tied. A thriv- can reduce the incidence of obesity and its re- ing workforce and controlling health costs are two lated diseases while lowering health care costs. of the most significant factors in the nation’s eco- TFAH and RWJF recommend increased fund- nomic recovery. However, we cannot and will not ing for CTGs and similar evidenced-based pro- see improvements in health care costs or disease grams, provided that the increase is not the rates until we make a more serious investment in result of a cut to another PPHF funding stream. addressing the obesity epidemic. 96 D. ully Implement the National Prevention Strategy and Action Plan F The National Prevention, Health Promotion and marketing practices aimed at children to pro- Public Health Council, chaired by the Surgeon vide the latest trends data and inform future general and composed of representatives from policy discussions. 17 federal agencies, released the groundbreak- n he Department of Labor is enforcing Section T ing National Prevention Strategy in 2011, which 7 of the Fair Labor Standards Act to ensure for the first time laid out a comprehensive action that covered female employees have reason- plan for improving the health of all Americans. able time and space for expressing breast milk. The Strategy also serves as a policy guide; for in- stance, all programs supported by the Prevention n he Food and Drug Administration is finaliz- T and Public Health Fund must be aligned with the ing menu labeling provisions of the Affordable Strategy’s goals. The Council released a follow-up Care Act to help provide consistent facts about Action Plan in 2012 that identified more than 200 food choices in chain restaurants. specific ways in which the federal government is Active Living working to implement the Strategy’s goals, which include promoting healthy eating and active liv- n he Department of Transportation is provid- T ing. Key federal actions under way include:331 ing funding for states and communities to in- crease active transportation options such as Healthy Eating walking paths and bike lanes. n he Department of Defense is improving T n HS is incorporating physical activity recom- H nutrition standards across the military by mendations into Head Start and other early updating menu standards at all base dining childhood education programs and dissemi- facilities and providing nutrition education nating resources to promote the National and obesity counseling to all military retirees. Physical Activity Guidelines for Americans. n HS is implementing a program to encourage H n he Department of Veterans Affairs is imple- T federal agencies to purchase and serve foods menting weight management programs such that meet standards consistent with the Dietary as screenings and support groups for veterans Guidelines for Americans. In addition, USDA who are overweight or obese. is working to better align agriculture policies with the nutrition goals of the DGA. TFAH and RWJF recommend continued imple- mentation of the National Prevention Strategy n he Federal Trade Commission (FTC) is T across all of the 17 participating federal agencies. monitoring and analyzing food and beverage E. inalize the Interagency Working Group on Food Marketed to Children Guidelines F The Interagency Working Group on Food Mar- Finalized recommended guidelines from the keted to Children (IWG), comprised of repre- IWG were expected in late 2011. However, in an sentatives from the FTC, CDC, FDA and USDA, omnibus FY 12 appropriations bill, Congress re- was directed by Congress to develop recom- quired the IWG to complete a cost-benefit anal- mendations for standards for food marketed ysis on its recommendations prior to releasing to children. Last year, the IWG issued a set of its final recommendations, which has delayed proposed voluntary principles to help guide their release indefinitely. industry efforts to improve the nutritional pro- TFAH and RWJF recommend that the IWG final- file of foods marketed to children. During the ize and release strong, voluntary guidelines for public comment period, members of the food food marketed to children. In the interim, food and beverage industry proposed a separate set and beverage companies should work together of standards that were not as rigorous as those with scientific, public health and consumer groups suggested by IWG. to strengthen industry standards on their own. 97 F. Expand Opportunities to Promote Physical Education and Physical Activity in Schools The Elementary and Secondary Education Act would provide federal funding for schools to (ESEA), first enacted in 1965 and last reau- hire more trained physical education teachers, thorized in 2002 as the No Child Left Behind as well as for researchers to further study how Act, authorizes all federal education programs. physical education and physical activity affect States and localities are largely responsible for academic achievement. determining core education standards in the Additionally the Carol M. White Physical Edu- United States—and provide the bulk of fund- cation Program, currently the centerpiece ing toward that end—but there is a role for the ESEA program that supports physical activity in federal government to set educational bench- schools, should be expanded. Additional pro- marks that states and schools must meet. Should posals worth considering include the authoriz- Congress take up reauthorization legislation in ing of a new Office of Safe and Healthy Students 2013, there are a number of important ways at the U.S. Department of Education, giving in which ESEA could be strengthened to pro- schools the option of using Title I and Title II vide additional funding to states and support funds to support physical education, and ensur- to schools to promote physical education and ing that School Improvement Grant funding physical activity without usurping state control. can be used to encourage school environments For instance, the next ESEA authorization that foster physical health. should include provisions of the FIT Kids Act TFAH and RWJF urge Congress to make physi- that require local education agencies and school cal education and physical activity a priority as boards to publish how much progress they have it reauthorizes the Elementary and Secondary made in meeting national standards for physi- Education Act. cal education and physical activity. The bill also G. Fully Support Healthy Nutrition in Federal Food Programs A range of programs included in the Agricul- promoting healthier food options for all Ameri- ture Appropriations Act and the Farm Bill, cans. At a minimum, current SNAP eligibility, such as the Supplemental Nutrition Assistance benefit levels, and program integrity should be Program and SNAP Nutrition Education, the maintained to ensure that low-income Ameri- Emergency Food Assistance Program, the Fresh cans have the resources necessary to afford a Fruit and Vegetable Program, and the Healthy nutritious diet and prevent hunger. Food Financing Initiative, can have a major Additionally, TFAH and RWJF support the in- impact on improving nutrition for millions of clusion of HFFI in the final Farm Bill. HFFI Americans, particularly lower-income families. provides one-time financing through grants SNAP funding, for example, has swelled during and loans to a variety of healthy food retail- recent years because the economic downturn ers, from full-service supermarkets, corner has caused millions of additional Americans to stores and farmers markets that want to set rely on its services. Opponents are concerned up shop or need to renovate or expand their about the potential waste of federal resources. stores in low income urban or rural commu- Particularly in times such as these, federal as- nities. This initiative helps boost employment sistance must be carefully scrutinized to prevent and maintain the vitality of rural communities fraud, maximize accountability, and ensure that and urban neighborhoods. HFFI was included funding is directed towards eligible beneficia- in the Senate version of the Farm Bill and we ries. The bottom line, however, is that providing endorse this approach. full support for these programs is essential to 98 H. Encourage Full Use of Preventive Services and Connect Clinical Care with Obesity-Prevention Outside of the Doctor’s Office Under the ACA, starting in 2014, public and pri- venting obesity and managing obesity-related vate insurers will be required to cover preventive diseases requires a balance between receiving services recommended by the U.S. Preventive clinical health care and making healthy lifestyle Services Task Force—such as obesity counsel- choices. Providing direct support for effective, ing for children and adults—at no charge to evidence-based programs—as well as payments policyholders. for beneficiaries to participate in them—is criti- cal to achieving this goal. Making sure Americans access and use these ser- vices will require a significant public education TFAH and RWJF recommend the Centers for and outreach effort. A number of studies have Medicare and Medicaid Services (CMS) promote shown that even when free preventive services are increase use of cost effective, community-based available, a lack of knowledge about their availabil- prevention, health education and counseling for ity precludes many individuals from taking advan- Medicare and Medicaid beneficiaries, including tage of these services.332 Education campaigns are by expanding the scope of practitioners who are particularly important to reach lower-income and eligible to be reimbursed for services for inten- minority communities that have been traditionally sive behavioral therapy for obesity (IBTO), to underserved by the health care system. include care beyond the doctor’s office or other clinical care settings. This would be consistent In June 2012, the USPTF recommended cover- with the new June 2012 U.S. Preventive Services age for community-based obesity counseling. Task Force recommendation that doctors either Primary care physicians need to know that these provide direct counseling on nutrition and activ- programs are now recommended and covered ity to their patients who are obese — or “offer for their patients. At the same time, the public healthful diet and physical activity interventions health community should be communicating by referring these patients to community-based with health care providers about the specific pro- organizations.” CMS would also be setting a grams to which their patients can be referred. strong precedent for how private insurers can In addition, Medicare, Medicaid and private provide better support for their beneficiaries insurers are all exploring new ways of provid- through community prevention as well. ing a better continuum of care to patients. Pre- Recommendations from the Institute of Medicine and Bipartisan Policy Center (BPC) Earlier this year, two organizations — the IOM In June 2012, the BPC issued Lots to Lose: How and the Bipartisan Policy Center (BPC) — issued America’s Health and Obesity Crisis Threatens our notable sets of recommendations for tackling the Economic Future, which includes ideas to reduce obesity epidemic among scientists, public health rates of obesity and chronic diseases. The BPC is- experts and across the political spectrum. sued the report as part of its Nutrition and Physical Activity Initiative, led by former Agriculture Secre- In May 2012, a group of leading policy, research taries Dan Glickman and Ann M. Veneman, former and public health experts developed the IOM’s Health and Human Services Secretaries Mike groundbreaking Accelerating Progress on Leavitt and Donna E. Shalala, and various other Obesity Prevention: Solving the Weight of the experts, policymakers and stakeholders. Nation, which identified faster ways to prevent obesity and related health concerns. TFAH and RWJF commend the important rec- ommendations from the IOM and BPC. 99 IOM Committee on Accelerating Progress in Obesity Prevention Recommendations The IOM was charged with developing goals, recommenda- n ntroduce, modify and utilize health-promoting food and I tions, strategies and action steps that can be implemented in beverage retailing and distribution policies the short term to accelerate progress in obesity prevention n Broaden the examination and development of U.S. agri- over the next 10 years.333 culture policy and research to include implications for the The committee put together five goals: American diet n Make physical activity an integral and routine part of life; Recommendation 3: Industry, educators, and governments should act quickly, aggressively and in n Create food and beverage environments to ensure that a sustained manner on many levels to transform the healthy food and beverage options are the routine, easy environment that surrounds Americans with messages choice; about physical activity, food and nutrition. n Transform messages about physical activity and nutrition; n evelop and support a sustained, targeted physical D n Expand the role of health care providers, insurers and activity and nutrition social marketing program employers in obesity prevention; and, n mplement common standards for marketing foods and I n Make schools a national focal point for obesity prevention.334 beverages to children and adolescents Recommendations and strategies to help the nation achieve n Ensure consistent nutrition labeling for the front of the five goals include:335 packages, retail store shelves, menus and menu boards that encourages healthier food choices Recommendation 1: Communities, transportation of- ficials, community planners, health professionals and n Adopt consistent nutrition education policies for federal governments should make the promotion of physical programs with nutrition education components activity a priority by substantially increasing access to Recommendation 4: Health care and health service places and opportunities for such activity. providers, employers and insurers should increase n Enhance the physical and built environment the support structure for achieving better population health and obesity prevention. n Provide and support community programs to increase physical activity n Provide standardized care and advocate for healthy com- munity environments n Adopt physical activity requirements for licensed child care providers n Ensure coverage of, access to, and incentives for routine obesity prevention, screening, diagnosis and treatment n Provide support for the science and practice of physical activity n Encourage active living and healthy eating at work Recommendation 2: Governments and decision makers n Encourage healthy weight gain during pregnancy and breast- in the business community/private sector should make feeding, and promote breastfeeding-friendly environments a concerted effort to reduce unhealthy food and bever- Recommendation 5: Federal, state and local govern- age options and substantially increase healthier food ment and education authorities, with support from and beverage options at affordable, competitive prices. parents, teachers and the business community and n Adopt policies and implement practices to reduce over- the private sector, should make schools a focal point consumption of sugar-sweetened beverages for obesity prevention. n ncrease the availability of lower-calorie and healthier I n equire quality physical education and opportunities for R food and beverage options for children in restaurants physical activity in schools n Utilize strong nutritional standards for all foods and bev- n Ensure strong nutritional standards for all foods and bev- erages sold or provided through the government, and en- erages sold or provided through schools sure that these healthy options are available in all places n Ensure food literacy, including skill development, in schools frequented by the public 100 Obesity Recommendations from the Bipartisan Policy Center336 Healthy Families n Public-sector institutions should continue to lead by exam- n HHS and USDA should extend federal guidelines for diet ple, promoting healthy foods and physical fitness as a means and physical activity to all children under six and enhance to enhance employee performance, both in the military and public awareness and understanding of these guidelines. within the civilian workforce. n USDA should ensure that all its nutrition assistance pro- n amilies and local governments should make creative use of F grams reflect and support federal dietary guidelines. technology to increase physical activity. n All key institutions—including hospitals, workplaces, communi- n ocal governments should use the planning process to change L ties, government and insurance providers—should support and the built environment in ways that promote active living. promote breastfeeding with the goal of substantially increasing Public Awareness and Marketing U.S. breastfeeding rates for the first six months of an infant’s life. n The food industry should adopt uniform standards for what Healthy Schools constitutes “better for you” foods using the Institute of Medi- n Childcare providers should improve nutrition and physical cine Phase 2 report as a starting point and making sure indus- activity opportunities for preschool-aged children. try standards are aligned with the U.S. Dietary Guidelines. n Schools should improve food and nutrition education by ag- n The Ad Council or similar organizations should coordinate a gressively implementing the Healthy Hunger-Free Kids Act. multi-media campaign to promote healthy diet and physical activity, funded by leading private sector companies in col- n Schools should improve nutrition and physical activity offer- laboration with federal agencies. ings, in partnership with the private sector. n ood retailers should adopt in-store marketing and product F n Federal, state and local governments, along with private placement strategies to promote the purchase of healthier, partners should explore all available avenues to increase lower calorie products. quality physical activity in schools. n States and localities should continue to innovate and experiment Healthy Workplaces with ways to promote healthier foods in the marketplace. n CDC, in partnership with private companies, should develop Food and Farm Policy a database of exemplary workplace wellness programs with a rigorous cost/benefit analysis to help scale up exiting best prac- n USDA, in collaboration with other stakeholders, should tices in both the private sector and within government. The identify and address barriers to increasing the affordability Small Business Administration should provide support here. and accessibility of fruits, vegetables and legumes. n The federal government should both scale up successful n USDA should identify and pursue further opportunities to workplace wellness programs and continue exploring inno- promote health and nutrition through nutrition assistance vative approaches. programs. n Congress should continue sustained support for relevant Healthy Communities research by offices of USDA. n Nutrition and physical activity training should be incorpo- rated in all phases of medical education—medical schools, Information Sharing and Analysis residency programs, credentialing processes and continuing n CDC and HHS should continue robust efforts to collect and education requirements. disseminate information on food, physical activity and health— n Nonclinical, community-based care is a critical tool in prevent- including information on the social determinants of health and ing obesity and chronic disease. We need to train and deploy future costs—and Congress should continue to support these a prevention workforce to deliver this kind of preventive care. monitoring and information-gathering functions. n Public and private insurers should structure incentives to n Public- and private-sector organizations active in this field reward effective, community-based, prevention-oriented should partner to establish a national clearinghouse on services that have demonstrated capacity to reduce costs health-related nutrition and physical activity initiatives. The significantly over time. clearinghouse should provide links to further resources, technical assistance, coordination and partnership opportu- n Large, private-sector institutions should procure and serve nities, and up-to-date research findings. healthier foods, using their significant market power to shift food supply chains and make healthier options more avail- able and cost-competitive. 101 APPENDIX A: PHYSICAL ACTIVITY AND NUTRITION TRENDS W eight is determined by an energy balance between what an individual eats and how active he or she is. The trend in America over the past 20 years to 30 years has been a decrease in physical activity combined with an increase in food intake, particularly of less nutritious food. The following section outlines how patterns have changed and current recommendations for improving health. A. Physical Activity Sixty percent of Americans are not active In 2011, only 29 percent of high school students enough to achieve health benefits, and more had participated in at least 60 minutes per day than a quarter of adults do not engage in any of physical activity on each of the seven days leisure-time physical activity.337, 338 before the survey, while 14 percent had not participated in 60 or more minutes of any kind In 2010, fewer than 50 percent of adults met the of physical activity on any day during the week 2008 federal physical activity guidelines for aer- before the survey.340 obic activity (based on leisure-time activity).339 SOME KEY TRENDS IN INSUFFIENT PHYSICAL ACTIVITY IN AMERICA Adults s Non-leisure-time physical activity” is defined as energy “ n More than a quarter of U.S. adults do not engage in any leisure- spent in a normal day outside of sports, exercise and rec- time physical activity (i.e., any physical activities or exercises reation. This includes manual labor on the job, walking such as running, calisthenics, golf, gardening or walking).341 and biking to work and household chores.350 s The percentage of adults who do not engage in any leisure- n A majority of U.S. adults ages 20 to 74 walk less than two time physical activity is higher among Blacks (31.9 percent) to three hours per week and accumulate less than 5,000 and Latinos (34.6 percent) than Whites (22.2 percent).342 steps per day.351 U.S. physical activity guidelines call for adults to walk 10,000 steps daily. n A study of more than 30,000 healthy adult U.S. women found that middle-aged women need at least an hour of n Car usage has significantly reduced physical activity by its moderate activity a day to maintain a healthy weight with- frequent use for short trips for shopping, going to the clean- out restricting calories.343 ers and other errands, and taking children to school.352 s or more than 66 percent of middle-aged women who are F Youth already overweight or obese, even more exercise is recom- n Current studies show that most youth do not meet physical mended to avoid gaining weight without eating less.344, 345 activity guidelines that recommend engaging in 60 minutes or n Physical activity is significantly associated with better sur- more of moderate-to-vigorous physical activity per day. 353,354 vival and function among the very old (age > 85 years).346 n An analysis of accelerometer data for children and adults n Sedentary adults pay $1,500 more per year in health care shows that the amount of time spent in moderate-to-vigorous costs than physically active adults.347 physical activity plummets as children reach adolescence.355 n Studies suggest that moderate-to-high levels of physical ac- n The number of children walking to and from school has de- tivity substantially reduce, or even eliminate, the mortality clined dramatically over the past 40 years, from 48 percent risk of obesity.348 of students in 1969 to 16 percent of students in 2001.356 n Non-leisure time physical activity has decreased substan- n There is substantial evidence that physical activity has a pos- tially in the past 20 years to 30 years due to increasing itive effect on students’ academic performance, including mechanization at work and at home.349 grades and standardized test scores, according to a review of 50 studies conducted by CDC.357 102 THE IMPACT OF THE BUILT ENVIRONMENT ON PHYSICAL ACTIVITY Physical Activity n Less safe neighborhoods were associated with decreased n Neighborhoods with high levels of poverty are significantly levels of physical activity according to a study of more than less likely to have places where children can be physically ac- 12,000 students in grades 8-10 who live in urban, suburban tive, such as parks, green spaces and bike paths and lanes.361 and rural neighborhoods.358 n n general, states with the highest levels of bicycling and walk- I s The same study found students’ perception of safety as ing have the lowest levels of obesity, high blood pressure and they traveled to and from school also was associated diabetes, and have the greatest percentage of adults who meet with physical activity levels.359 the recommended 30-plus minutes a day of physical activity.362 n Children and teens living in neighborhoods with more green space, such as parks, playing fields, trails and schoolyards, were less likely to be overweight than their counterparts in less-green neighborhoods.360 Walking in America: Only a Pastime? Walking is free and just a few of the proven benefits include compare how much Americans walk today as opposed to a lower risk of Alzheimer’s, improved academic perfor- the past, a study in Medicine & Science in Sports and Exercise mance, reduced depression, lower blood pressure and reports that researchers provided pedometers to a group increased self-esteem, yet, for many Americans, walking has of Old Order Amish in Canada who do not drive cars and become just a means of getting to the car.363 found that they averaged 18,000 steps per day.366  The previous studies include most of the limited statistics Average Steps Per Day currently available about the state of walking in America. 20000 Trying to figure out exactly how much Americans walk, and 18000 16000 why walking has decreased so dramatically, is difficult with 14000 limited data, but, while walking statistics are hard to come Number of Steps 12000 by, there is more robust information on changes in driving. 10000 The National Household Travel Survey reveals that in 1969 a 8000 person averaged 2.32 trips and 20.64 miles in a car per day, 6000 4000 which increased to 3.35 trips and 32.73 miles in 2001.367 2000 While there are various organizations dedicated to advocat- 0 Australian Swiss Japanese Average Old order American Canadian Child in ing for bicyclists, there are few advocacy groups working adults American Amish child child Britain 6-19 yrs. 5-19 yrs. 8-11 yrs. solely for the rights of walkers.368 Scott Bricker, director of the nonprofit organization America Walks says that, “Walk- * Old Order Amish do not drive cars.    Note: Rates for children’s number of steps show a reported low-to-high range. ing is not something that people rally around — it’s very pe- destrian.”369 The lack of excitement also may be the cause of the limited statistics surrounding walking in America. Ac- Americans take the fewest steps of any industrialized na- cording to Bricker, “[the] collection of information around tion.  Recent pedometer studies show adults in Australia walking is quite poor and inconsistent.”370 The U.S. Census and Switzerland average almost 10,000 steps a day, with reports the most accurate measures of walking, but they adults in Japan averaging more than 7,000, but in the United only measure walks that are a part of a work commute. States adults manage little more than 5,000 steps per day.364   Unfortunately, those questions miss out on a lot of walks, as Children take significantly more steps than adults; steps per commuting accounts for less than 15 percent of all trips.371 day range between 9,000 and 13,000 for American children Twenty-eight percent of all trips taken in America are under and youth, which is similar to children in Britain and Canada, a mile, yet most of these trips are taken in the car.372 who average between 11,000 and 13,000.365  In an effort to 103 2008 PHYSICAL ACTIVITY GUIDELINES FOR AMERICANS In 2008, the U.S. Department of Health and Human Services Adults with Disabilities issued the first-ever Physical Activity Guidelines for Americans.373 n Adults with disabilities who are able should get at least two- The Guidelines provide information on the types and amounts and-a-half hours of moderate aerobic activity per week, or of physical activity that provide substantial health benefits one-and-a-quarter hour of vigorous aerobic activity per week. for Americans age 6 and older. The main idea behind the Guidelines is that regular physical activity over months and n Adults with disabilities should incorporate muscle-strength- years can produce long-term health benefits. ening activities involving all major muscle groups two or more days per week. Adults n Those who are not able to meet the guidelines should en- n The guidelines recommend that adults engage in a minimum gage in regular physical activity according to their abilities of two-and-a-half hours each week of moderate-intensity and should avoid inactivity. exercise, or one-and-a-quarter hour of vigorous physical activity. Adults with Chronic Medical Conditions s Brisk walking, water aerobics, ballroom dancing and gen- n Adults with chronic conditions get important health benefits eral gardening are examples of moderate-intensity aero- from regular physical activity. They should do so with the bic activities. Vigorous-intensity aerobic activities include guidance of a health care provider. race walking, jogging or running, swimming laps, jumping Children and Adolescents rope and hiking uphill or with a heavy backpack. n Children and adolescents should engage in 60 minutes or n Aerobic activity should be performed in episodes of at least more of physical activity daily. 10 minutes.  s Aerobics: Most of the 60 or more minutes should include n For more extensive health benefits, adults should increase either moderate- or vigorous-intensity aerobic physical their aerobic physical activity to five hours per week of activity, and should include vigorous-intensity physical ac- moderate-intensity or two-and-a-half hours per week of tivity at least three days a week. Examples of moderate- vigorous-intensity aerobic physical activity. intensity aerobic activities include hiking, skateboarding, n Adults should incorporate muscle strengthening activities rollerblading, bicycle riding and brisk walking. Vigorous- such as weight training, push-ups, sit-ups, carrying heavy intensity aerobic activities include bicycle riding, jumping loads or heavy gardening at least two days per week. rope, running and sports such as soccer, basketball and ice or field hockey. Older Adults s Muscle-strengthening: The 60 or more minutes of daily n Older adults should follow the guidelines for other adults physical activity should include muscle-strengthening when it is within their physical capacity. If a chronic condi- activities at least three days a week. Examples of muscle- tion prohibits their ability to follow those guidelines, they strengthening activities for younger children include: should be as physically active as their abilities and conditions gymnastics, playing on a jungle gym and climbing a tree. allow. If they are at risk of falling, they should also do exer- Examples of muscle-strengthening activities for adolescents cises that maintain or improve balance. include; push-ups, pull-ups and weightlifting exercises. Pregnant Women s Bone-strengthening: The 60 or more minutes of daily n During pregnancy and the time after delivery, healthy physical activity should include bone-strengthening activi- women should get at least two-and-a-half hours of moder- ties at least three days a week. Examples include jumping ate-intensity aerobic activity per week, preferably spread rope, running and skipping. throughout the week. n Encouraging young people to participate in physical activi- n Pregnant women who habitually engage in vigorous aerobic ties that offer variety, are enjoyable, and are age-appropri- activity or who are highly active can continue during preg- ate can increase the amount of time children and youths nancy and the time after delivery, provided they remain spend being active. healthy and discuss with their health care provider how and when activity should be adjusted over time. 104 Are Physicians Encouraging Physical Activity? Data collected through the National Health In- well as for both males and females. Physicians terview Survey (NHIS) show improved trends in were more likely to discuss physical activity sharing information about physical activity from programs with patients who were either over- physician to patient over the past 10 years.374 In weight or obese, but continued to advise all pa- 2010, almost one-third of adults who had seen a tients about the benefits of physical activity.377 physician or health professional in the previous The trends show that the health community is 12 months were advised to start or continue an making efforts to improve communication be- exercise program.375 These figures improved tween patients and physicians about the impor- significantly and showed an increase of ap- tance of physical activity, yet physicians are still proximately 10 percent from 2000 to 2010.376 only discussing physical activity with less than Physicians or other health providers improved half of their patients. the rates among all age groups and ethnicities, as Get Active to Feel Good A recent study in the Journal of Sports and Ex- their physical activity, the amount of sleep they ercise Psychology found that undergraduates got each night and their overall mental state and who were more active felt better than their then turned the journals over to researchers.379 less-active peers.378 Almost 200 college-aged The researchers found that physical activity was students kept journals for eight days, tracking also associated with more positive moods.380 105 B. NUTRITION TRENDS IN AMERICAN’S UNHEALTHY EATING PATTERNS The American diet has skewed towards large portion sizes that per day for an individual who consumes 2,000 calories a day, and are high in fat and calories. The USDA reports that Americans someone who consumes about 1,400 daily calories should have are not meeting the 2005 Dietary Guidelines for Americans. In 11/2 cups of vegetables and 11/2 cups of fruits per day. order to meet them, Americans would need to substantially n July 2012 survey found that Americans are trying to eat A lower their intake of added fats, refined grains, sodium and added more fruits and vegetables, but they are still consuming less sugars and sweeteners, and increase their consumption of fruits, than half of national recommendations.388 vegetables, whole grains and low-fat milk and milk products.381 Some unhealthy eating habits that have developed over the More Sugar past few decades include: n onsumption of “added sugars,” which are sugars and C syrups that are added to foods or beverages when they More Calories and Fat are processed or prepared and does not include naturally n Americans’ average daily caloric intake is 300 calories higher occurring sugars such as those in milk and fruits, is nearly than it was in 1985 and 600 calories higher than in 1970, ac- three times the USDA recommended intake.389 cording to 2008 USDA data.382 n verage consumption of added sugars increased 14 percent A n Americans consumed an average of 640 calories worth of from 1970 to 2008.390 added fats per person per day in 2008.383 A Large Increase in Soda, Fruit Juice and Other n Children ages 2–18 consume almost three snacks a day, and Sugar-Sweetened Beverage Consumption snacking accounted for up to 27 percent of children’s daily caloric intake.384 n ugar-sweetened beverages make up nearly 11 percent of S children’s total caloric consumption.391 Bigger Portion Sizes Portion Distortion n dults who drink a soda or more per day are 27 percent A 20 Years ago Today n According to National Bagel more likely to be overweight than those who do not drink Heart Lung and Blood Insti- sodas, regardless of income or ethnicity.392 tute (NHLBI), an individual n rom 1988-1994, adults ages 20 and older increased their F who consumes the follow- 3 inches (diam.) 6 inches (diam.) consumption of sugar-sweetened beverages by 58 percent, ing meal today compared Cheeseburger and from 1999-2004 consumption of sugar-sweetened bever- to 20 years ago would con- ages increased by 63 percent among the same population.393 sume almost 1,600 more calories in one day.385  n y 1999–2004, adults ages 20-24 consumed 12 percent of B 4.5 ounces 8 ounces their total daily intake from sweetened beverages.394 s reakfast: a bagel B Popcorn (6 inches in diameter) n hildren who reduced their consumption of added sugar by C and a 16-ounce coffee the equivalent of one can of soda per day had improved glucose with sugar and milk. and insulin levels. This means that parents can reduce the risk of type 2 diabetes in their children by eliminating one can of soda s Lunch: two pieces of pep- 5 cups 11 cups per day, regardless of any other diet or exercise changes.395 peroni pizza and a Soda 20-ounce soda. A Major Increase in Eating Out s inner: a chicken D n ince the 1960s, the money Americans spend on foods eaten S Caesar salad and a outside the home has nearly doubled; the average American 20-ounce soda. 6.5 ounces 20 ounces household spent $2,505 on food away from home in 2010.396,397 Fewer Fruits, Vegetables and Whole Grains n ore than 40 percent of adults report that restaurants are M an essential part of their lifestyle.398 n rom 2005-2008 adults consumed 1.1 to 1.8 servings of fruit per F day and 1.3 to 2.2 servings of vegetables per day.386 Teenagers n s of 2004, 63 percent of children ages 1–12 ate out at a A eat only 0.9 cups. Overall, adolescents consume 0.9 to 1.1 cups restaurant one to three times per week.399 of vegetables, with only 4 percent of those 15-19 eating 2 or n or 2012, restaurants project food and drink sales of $631.8 F more cups of fruits per day and less than 2 percent of all children billion, compared with just $379 billion in 2000.400 eating 2.5 or more cups of vegetables per day.387  The recom- mended values are two cups of vegetables and two cups of fruits 106 NUTRITION: BIOCHEMICAL INDICATORS In 2012, CDC released the second report in a Key findings from the report about vitamin series on biochemical indicators.  The goal of The D include the following:404 National Report on Biochemical Indicators of Diet n evels generally decreased as age increased. L and Nutrition in the U.S. Population is to inform physicians, scientists, public health officials and n ales and females had similar levels. M policymakers about varying levels of biochemicals n mong three racial and ethnic groups studied A in a person or group of people, and how those in the report, non-Hispanic Blacks had the levels affect health outcomes.401  The results help lowest vitamin D levels, Mexican Americans inform experts on the need for diet and nutrition were in the middle and non-Hispanic Whites recommendations to address disease, obesity and had the highest levels. improve health. The information in the report, which was collected through the NHANES, con- Iron is an important nutrient that is needed to tains information for 58 biochemical indicators.  carry oxygen to tissue, and iron deficiency is linked to reduced physical capacity, poor preg- Some of the key findings include the nancy outcomes and poor cognitive develop- following:402 ment among infants and adolescents. n Vitamin B6, iron and vitamin D are the three Key findings from the report about iron in- nutrients for which the greatest number of clude the following:405 people were deficient. n hildren ages 6 to 11 had the lowest iron C n itamin A, vitamin E and folate are the three nu- V levels compared with other age groups. trients with the lowest prevalence of deficiency. n egardless of the indicator selected for iron R n Vitamin C and vitamin B12 had intermediate measurement, the likelihood of being iron prevalence of deficiency. deficient varied by race/ethnic group. Folate is naturally occurring in leafy green vegeta- n hile children and women of childbearing W bles, fruits, peas and dried beans and is especially age were at risk for iron deficiency, men were important during pregnancy and infancy. To re- at risk for iron excess. duce the risk of neural-tube defects in newborns, FDA began fortifying foods with folic acid in 1998. Iodine is an essential element that takes part in regulating the body’s metabolic processes related Key findings from the report about folate to growth and development. Globally, iodine include the following:403 is added to salt and seafood, but in the United n Of all age groups, older people had the high- States it is not mandatory, so most people rely on est blood folate levels. dairy products and bread for their iodine intake. Iodine deficiency is the most preventable cause n Females generally had higher levels than males. of mental retardation, and also is related to hy- n Non-Hispanic Blacks had the lowest, non- pothyroidism, goiter, cretinism and other growth Hispanic Whites had the highest, and Mexican and developmental abnormalities. Americans had intermediate folate status. Key findings from the report about iodine Vitamin D is naturally occurring in fish-liver oils, include the following:406 fatty fishes, mushrooms, egg yolks and liver, and n he lowest levels of iodine were observed in T is commonly added to milk and other foods in young women, while the highest levels were the United States. Ultraviolet rays from the sun observed in children. help vitamin D transport from the skin to the liver. Vitamin D is essential for bone health, and n o consistent pattern was observed with N may be important for muscle strength and pro- regard to race or ethnicity. tecting against cancer and type 2 diabetes. n rine iodine levels have been relatively stable U since the late 1980s. 107 THE IMPACT OF THE BUILT ENVIRONMENT ON NUTRITION n A systematic review of nearly 50 studies n 2003 study showed a direct relationship A examining the built environment found that between living near at least one supermarket increasing supermarket access for disadvan- and meeting the U.S. Dietary Guidelines for taged individuals or areas, identified by low Americans for fruit and vegetable intake.  The socioeconomic status, black race or Hispanic presence of each additional supermarket was ethnicity, had potential to reduce obesity- related to a 32 percent increase in fruit and related health disparities.407 vegetable consumption among Blacks and an 11 percent increase among Whites.409 n A large-scale study of New York City adults found that increasing the density of healthy n study of nearly 700 neighborhoods found that A food outlets, such as supermarkets, fruit and lower-income areas have access to half as many vegetable markets, and natural food stores is supermarkets as the wealthiest areas. Predomi- associated with lower BMIs and lower preva- nantly minority and racially mixed communities lence of obesity.408 have access to fewer supermarkets compared with predominantly White communities.410 2010 DIETARY NUTRITION GUIDELINES FOR AMERICANS The Dietary Guidelines for Americans are a joint n onsume three or more ounce-equivalents of C initiative of the Department of Health and Human whole-grain products per day. At least half of Services and the Department of Agriculture.411 grain intake should come from whole grains. The Dietary Guidelines, which have been pub- n onsume three cups per day of fat-free or C lished every five years since 1980, provide people low-fat milk or milk products. with advice about how good dietary habits can promote health and reduce risk for major chronic n ncrease dietary intake of calcium, potassium, I diseases. They serve as the basis for federal food fiber, magnesium, and vitamins A, C, and E. and nutrition education programs. n void inactivity and sedentary behaviors; A Key Recommendations some physical activity is better than none, but n onsume a variety of nutrient-dense foods C it’s recommended that adults should engage and beverages within and among the basic in at least 150 minutes a week of moderate- food groups, while picking foods that limit the intensity or 75 minutes a week of vigorous- intake of saturated and trans fats, cholesterol, intensity aerobic activity. added sugars, salt and alcohol. Specific Recommendations for Children n Consume more dark green vegetables, or- and Adolescents ange vegetables, legumes, fruits, whole grains, n t least half of grains consumed should be A and low-fat milk and milk products. whole grain. Children ages 2–3 should con- sume two cups per day of fat-free or low-fat n Eat fewer calories, refined grains, added sug- milk or milk products, children ages 4-8 ars, and total fats. Eat foods lower in sodium. should drink 2.5 cups, and children age 9 and n uild healthy eating patterns during each stage of B older should drink three cups per day. life—childhood, adolescence, adulthood, preg- n educe intake of sugar-sweetened beverages R nancy and breastfeeding and older age—to meet and monitor the intake of 100 percent fruit juice. nutrient needs and appropriate calorie amounts. n ncrease dietary intake of calcium, potassium, I n Increase physical activity and reduce time fiber, magnesium and vitamin E. spent in sedentary behaviors. n articipate in one hour or more a day of mod- P Specific Recommendations for Adults erate- to- vigorous physical activity. n An adult consuming 2,000 calories per day should have two cups of fruit and two-and-a- half cups of vegetables. 108 APPENDIX B: Methodology for Behavioral Risk Factor Surveillance System for Obesity, Physical Activity, and Fruit and Vegetable Consumption Rates Methodology for Obesity and Other Rates Using BRFSS Annual Data All estimates were adjusted to account for the sample design and survey nonresponse using Data for this analysis were obtained from the the sample probability weight, _LLCPWT. Behavioral Risk Factor Surveillance System (BRFSS) dataset (publicly available on the web The following is a Question and Answer Docu- at www.cdc.gov/brfss). The data were reviewed ment Provided by CDC for the methodology and analyzed for TFAH and RWJF by Daniel used for 2011 BRFSS data Eisenberg, Ph.D., Associate Professor, Health Frequently Asked Questions AboutChanges Management and Policy at the University of to the Behavioral Risk Factor Surveillance Michigan School of Public Health. System BRFSS is an annual cross-sectional survey de- Q: What is the BRFSS? signed to measure behavioral risk factors in the adult population (18 years of age or older) liv- A: The Behavioral Risk Factor Surveillance Sys- ing in households. Data are collected from a tem is the largest ongoing telephone health random sample of adults (one per household) survey in the world. It is a state-based system of through a telephone survey. The BRFSS cur- health surveys established by the Centers for rently includes data from 50 states, the District Disease Control and Prevention in 1984. BRFSS of Columbia, and Puerto Rico. completes more than 400,000 adult interviews each year. Variables of interest included BMI, physical in- activity, diabetes, hypertension, and consump- For most states, BRFSS is their only source of pop- tion of fruits and vegetables 5 or more times a ulation-based health behavior data about chronic day. BMI was calculated by dividing self-reported disease prevalence and behavioral risk factors. weight in pounds by the square of self-reported BRFSS surveys a sample of adults in each state height in inches, then multiplied by 703. Obesity to get information on health risks and behav- is defined as BMI greater than or equal to 30. iors, health practices for preventing disease, An overweight adult was defined as one with a and healthcare access mostly linked to chronic BMI between 25 and 30. For the physical inactiv- disease and injury. The sample is representative ity variable a binary indicator equal to one was of the population of each state. created for adults who reported not engaging in physical activity or exercise during the previous Q: What are the changes that have been made thirty days other than their regular job. For dia- to BRFSS? betes, researchers created a binary variable equal A: The two BRFSS changes have been made to to one if the respondent reported ever being told keep the data accurate and representative of by a doctor that he/she had diabetes. Cases of the total population. These are making survey gestational and borderline diabetes were not calls to cell-phone numbers and adopting an counted as diabetes, and cases where the indi- advanced weighting method. vidual was unsure or refused to answer were ex- n he first change is including and then grow- T cluded from the analysis.Similarly, to calculate ing the number of interview calls made to cell prevalence rates for hypertension, researchers phone numbers. Estimates today are that 3 created a binary variable equal to one if the re- in 10 U.S. households have only cell phones. spondent answered “Yes” to the following ques- tion: “Have you ever been told by a doctor, nurse or n he second change is to replace the “post- T other health professional that you have high blood pres- stratification” weighting method with a more sure?” People reporting to have been borderline advanced method called ”iterative propor- hypertensive and women who reported being di- tional fitting,” also sometimes called “raking.”  agnosed with hypertension only while pregnant were not counted as having hypertension. 109 Q: Why is it necessary to increase the number of American Association of Polling and Opinion survey calls to cell-phone numbers? Research (AAPOR) in 2009, 2010, and 2011. A: During 2003—2009, the proportion of U.S. In September 2011, BRFSS provided states and adults who lived in cell phone-only households CDC programs with preliminary datasets that incor- increased by more than 700%, and this trend is porated the new methods so that early assessment continuing. Estimates are that currently 3 in 10 could be made of the effects of the new methods. U.S. households have only cell phones. The 2011 BRFSS dataset will be released by CDC These households increasingly were left out of the in June 2012. It will incorporate both changes: cell population that BRFSS seeks to characterize— phone responses and the new weighting method. adults 18 years of age or older who do not live in Q: How will these two changes affect each institutional settings. Using cell phones only is espe- state’s dataset? cially strong in younger age groups and among per- A: Including cell phone interviews and using the sons in certain racial and ethnic minority groups. new weighting method will keep BRFSS data ac- Because of differences in the characteristics curate and meaningful. Specifically, BRFSS data of people living in households with or without will better represent lower-income and minority landline telephones, all telephone surveys in populations, as well as populations with lower lev- the United States have had to adapt their meth- els of formal education.  The size and direction ods in response to the significant increase in of the effects will vary by state, the behavior under households that use cell phones only.  study, and other factors. Although generalizing is difficult because of these variables, it is likely that Q: Why is it necessary to adopt a different the changes in methods will result in somewhat method of data weighting? higher estimates for the occurrence of behaviors A: For the past several decades, BRFSS used a that are more common among younger adults statistical weighting method called “post-stratifi- and to certain racial and ethnic groups. cation.” However, the advent of easily accessible ultra-fast computer processors and networks Q: When will we first see BRFSS data that re- has allowed the BRFSS to adopt an advanced flects the two changes? weighting method called iterative proportional A: The first data reflecting the changes is the fitting, also known by its nickname, “raking.”  BRFSS 2011 dataset that CDC releases in June 2012. Raking differs from post-stratification because it incorporates adjustor variables one at a time Q: Can the 2010 BRFSS dataset be compared in an iterative process, rather than imposing with 2011 dataset? weights for demographic subgroups in a single A: It is always difficult to discern long-term trends process.  A key advantage of raking is that many by comparing one year to the next. Such compar- more variables are used than post stratification. isons will be especially difficult to make for 2010 In addition to the standard demographic vari- and 2011, given the change in BRFSS methods. ables of age, gender, and race and ethnicity, rak- ing uses variables such as education level, marital Changes in the 2011 data are likely to show in- status, renter or owner status, and phone source. dications of somewhat higher occurrences of risk behaviors common to younger adults and Q: What steps were taken to implement these to certain racial or ethnic minority groups. Such BRFSS changes? effects will vary for each state survey. CDC antici- A: In 2004 a panel of national survey experts pates small increases for health-risk indicators recommended that CDC make the two changes such as tobacco use, obesity, binge drinking, to ensure BRFSS data remained valid and use- HIV, asthma, and health status. ful. Beginning in 2006, how to best design and Shifts in observed prevalence from 2010 to 2011 implement the changes went through an exten- for BRFSS measures will likely reflect the new sive development process with experts, collabo- methods of measuring risk factors, rather than ration with the state BRFSS coordinators to pilot true trends in risk-factor prevalence. test the new methods, and training to ensure that state BRFSS coordinators understood the Q: Where can I learn more about the BRFSS changes and the rationale for them.  changes? The changes were discussed at the annual A: The BRFSS changes are discussed in detail BRFSS Conferences in 2007, 2008, 2009, 2010 in the June 7, 2012, MMWR Policy Note “Meth- and 2011; with CDC and state members of the odologic Changes in the Behavioral Risk Factor BRFSS Working Group; at training sessions; and Surveillance System in 2011 and Potential Ef- at meetings of NACCHO, APHA, CSTE, and the fects on Prevalence Estimates.” 110 APPENDIX C: METHODOLOGY FOR OBESITY AND RELATED DISEASE AND COST FORECASTING FOR 2020 AND 2030 As prepared by the research team from the Na- extent of this burden is, as yet, unclear, but the tional Heart Forum: economic impact will include decreased quality of life and fewer working years as well as rapidly The alarming growth of obesity around the rising healthcare costs. globe has caused some to describe it as an obesity epidemic. One recent study examined trends in Predicting future rates of obesity, disease and BMI from 1980 to 2008 for 199 countries and healthcare costs are helpful in order to guide found an increase in overweight and obesity policy towards ameliorating the epidemic, and in almost all countries, and estimated that 500 planning the most fair and effective division of million adults worldwide were obese in 2008.412 resources. In a previous report, we used a simu- Of the high income countries in the study, the lation model to project the likely health and eco- USA had the highest BMI. The most recently nomic consequences over the next two decades, published data from the National Health and if obesity were to continue to rise according to Nutrition Examination Survey (NHANES) has current trends.422 This model predicted that indicated that US adults had a mean body mass there would be 65 million more obese adults index (BMI; kg/m2) in the overweight range in the United States by the year 2030 and that (28.7) and that nearly 36% were obese.413 Fur- the medical costs associated with obesity-related thermore, the NHANES data suggests that the diseases would increase by 48 to 66 billion US rise in obesity may still be continuing in the USA, dollars every year. The simulation model also with men and women from some ethnic groups detailed what could be expected if interventions continuing to show a positive linear trend in were able to reduce BMI by either 1 percent or BMI and obesity rates even in the last decade.414 5 percent across the U.S. population, indicating that 2.4 million cases of diabetes and 1.7 million Obesity is a significant risk factor for many dis- cardiovascular diseases could be prevented. eases, contributing to a global health burden. Epidemiological studies have identified obesity Given evidence that obesity trends may differ as a specific risk factor for cardiovascular dis- between men and women, and between dif- eases (e.g. hypertension, coronary heart disease ferent ethnic groups, it is now important to and stroke), diabetes mellitus, osteoarthritis, make future predictions at a micro-level. This several types of cancer and other diseases too paper reports the result of micro-simulations numerous to be listed here.415,416,417,418,419,420,421 projecting obesity rates, disease prevalence and Given the current trend of global increases in associated healthcare costs up to 2030, for 51 obesity, the burden of these diseases is expected American states and territories. to continue to overwhelming levels. The full METHOD: BRFSS AND MODELING OVER TIME An individual’s body mass index (BMI) is data from the BRFSS, BMI was grouped in the defined as: following three categories: BMI"=w/h2 x 703 , 1) BMI < 25 : (normal weight) where w and h correspond to individual’s weight 2) BMI > 25 < 30 : (overweight) and height, respectively. BMI provides a simple 3) BMI >30 : (obese) measure of a person’s “fatness” or “thinness”. Al- though BMI is measured on a continuous scale, All models were fitted on bias-corrected BMI it is commonly grouped in three categories, measurements, which were obtained by calculat- namely, “underweight,” “normal-weight,” “over- ing BMI after correcting BRFSS data of height weight” and “obese.” In adults, BMI increases and weight for potential bias due to self-report- slowly with age and age-independent cut-offs ing. Bias for height and weight was assessed can be used to grade obesity.423 These cut-off by gender and age group (18-19, 20-24, 25-29, points are related to health risk but also are con- 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, venient round numbers.424 For the purpose of 65-69, 70-74, 75-79, 80+), and was estimated as estimating the trends for obesity in adults using the difference between means in population 111 height and weight obtained from BRFSS and morbidly obese individuals amongst all adults the National Health and Nutrition Examina- is P("BMI" >40)=P("BMI" >40-|I"BMI">30) tion Survey data collected over the time period P("BMI" >30)=p_2 (t) q_2 (t). 1999-2010. This method of estimating bias has To cover the complete range of ages and be- been discussed by Ezzati.425 Figure 1 illustrates cause data for children were not available in the extent of bias for height in men and women BRFSS, trends for obesity in children aged due to self-reporting. Height was over-reported 0-17 were modelled using national data from in BRFSS both in men and women, particularly NHANES. A model for the prediction of obe- in the older age groups. Figure 2 shows the sity levels covering an individual’s life span was extent of bias for weight in men and women. required for the micro-simulation process. BRFSS measurements for weight were under-re- ported by women by an average of 5 kilograms. The underlying assumption which allows the This discrepancy between actual and reported forecasting of obesity levels in the future is that weight was persistent up to age 65, after which the fitted model can provide valid estimates self-reporting was decreased with age. Bias by using extrapolation. This involves the assump- gender and age group was not found to change tion that the effect of any factor that may affect over time during the period from 1999 to 2010. obesity levels will remain constant over time. Ex- Pregnant women were not excluded from the amples of such factors include the demographic analyses, and the estimation of obesity trends characteristics by gender and age group of the was stratified by gender and age group (20-39, studied population, governmental policies, and 40-59, 60+). secular lifestyle changes. Any attempt of extrap- olation from a fitted model may involve assump- Let g=1,2,3, denote BMI group for normal tions which may be hard to verify and which may weight, overweight and obese, respectively. Let influence the validity of the attempted projec- ,p-g.(t) be the percentage of individuals with tions. Therefore, the forecasted levels of obesity BMI values which correspond to group g at cal- should be treated with caution. Nevertheless, endar year t. Multinomial regression was used to having faith in that our methodology is valid, model the percentage of individuals in each BMI and observing that the current levels of obesity group over time, using the following equations: show a clear increasing trend, we believe that our reported forecasts may prove very useful in future healthcare policy decisions. For the micro-simulation study, a virtual popu- lation was generated with demographic charac- teristics matching those of the observed data. Health trajectories were simulated over time allowing virtual individuals to contract, survive or die from a set of obesity related diseases and types of cancer (coronary heart disease, stroke, breast cancer, kidney cancer, colorectal cancer, Thus, all percentages ,p-1.,t., ,p-2.,t., ,p-3.,t., are oesophageal cancer, endometrial cancer, gall bound within [0,1], and add up to unity. The bladder cancer, diabetes, arthritis, hypertension, group of obese individuals (BMI>30) was fur- liver cancer, and pancreatic cancer). In this sto- ther divided into two subgroups, namely those chastic process, the risk of dying or contracting with 30<BMI<40, and those with BMI>40 (mor- a medical condition was adjusted for obesity bidly obese). Let s=1,2, denote BMI subgroup levels as forecasted by models (1), (2), and (3). 30<BMI<40 and BMI>40, respectively. Amongst Simulating BMI growth at an individual’s level, those with BMI>30, let ,q-g.(t) be the percentage involved the assumption that people’s BMI of individuals with BMI values corresponding to changes throughout their lives in such a way subgroup s at time t. The percentage of morbidly that they always stay on the same BMI percentile. obese individuals amongst those classified as This rule may not be too far from the truth and obese was modelled using logistic regression by it means that fat people stay fat and thin people stay thin. Moreover, the micro-simulation pro- cess was carried out so that when virtual individu- als progressed through different age groups, the Equation (3) implies that q_2 (t)=exp[(a_0+a_1 simulation utilised the forecasted obesity levels t})]/{1+exp{a_0+a_1 t}} . Using Bayes’ rule of of the new age group. The micro-simulation was conditional probabilities, the prevalence of performed under three distinct scenarios: 112 Scenario 0: Individuals’ trajectories were simulated assuming a 5% population BMI reduction rela- over the period between 2010 and 2030, using BMI tive to Scenario 0. growth as predicted by models (1), (2), and (3). The disease prevalence and health care costs Scenario 1: Individuals’ trajectories were simu- have been modelled for 13 diseases across all 51 lated over the period between 2010 and 2030, states. The costs have been predicted up to 2030 assuming a 1% population BMI reduction rela- and have been simulated for three scenarios. tive to Scenario 0. Throughout this report, all figures for cost are presented as millions of US Dollars. Scenario 2: Individuals’ trajectories were simu- lated over the period between 2010 and 2030, 1.8 90 1.75 85 1.7 80 1.65 75 70 1.6 60 1.55 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age Group Age Group Mean height in men – NHANES Mean height in men – BRFSS Mean weight in men – NHANES Mean weight in men – BRFSS ■ Mean height in women – NHANES Mean height in women – BRFSS ■ Mean weight in women – NHANES Mean weight in women – BRFSS Figure 1: Self-reporting bias for height (m). Solid Figure 2: Self-reporting bias in weight (Kg). Solid lines correspond to mean height levels reported in lines correspond to mean weight levels reported NHANES. Dashed lines connect mean levels re- in NHANES. Dashed lines connect mean levels ported in BRFSS. Height is over-reported in BRFSS reported in BRFSS. Weight is under-reported in by both men and women. BRFSS by women. 113 Endnotes 1 or individuals, obesity is defined as a body mass F 18 Puhl R and Latner J. “Stigma, Obesity, and the Health index rate above 30. On an individual level, an adult of the Nation’s Children.” Psychological Bulletin, reducing BMI by one percent is the equivalent to a 133(4): 557-80, 2007. weight loss of 2.2 pounds (for an adult of average 19 Ibid. weight). According to CDC, the average weight of 20 Ibid. men is 194.7 and women is 164.7. http://www.cdc. gov/nchs/fastats/bodymeas.htm 21 Wang YC, Orleans CT and Gortmaker SL. Reaching the Healthy People Goals for Reducing Childhood 2 abey, SH, et al. A Patchwork of Progress: Changes in B Obesity: Closing the Energy Gap. Am J Prev Med, Overweight and Obesity Among California 5th, 7th, and doi: 10.1016/j.amepre.2012.01.018, 2012. 9th graders, 2005-2010. California Center for Public Health Advocacy and the UCLA Center for Health 22 Wang YC et al. Health and Economic Burden of the Policy Research. 2011. http://www.publichealthad- Projected Obesity Trends in the USA and the UK. vocacy.org/research/patchworkdocs/OFT%20 The Lancet, 378, 2011. brief_final.pdf (accessed April 2012). 23 Flegal KM, Carroll MD, Ogden CL, et al. Prevalence 3 Obesity in K-8 Students — New York City, 2006-07 to “ and Trends in Obesity among U.S. Adults, 1999- 2010-11 School Years.” MMWR Weekly. 2011: 60(49); 2008. Journal of the American Medical Association, 1673-1678. http://www.cdc.gov/mmwr/preview/ 303(3): 235-41, 2010. mmwrhtml/mm6049a1.htm?s_cid=mm6049a1_e (ac- 24 National Center for Health Statistics. “Prevalence cessed April 2012). of Overweight, Obesity and Extreme Obesity among 4 enter for Mississippi Health Policy. “Assessing the C Adults.” Impact of the Mississippi Healthy Students Act on Child- 25 Ogden CL, Carroll MD, Kit BK, Flegal KM. Preva- hood Obesity: Year Three Report.” http://www.mshealth- lence of Obesity in the United States, 2009-2010. NCHS policy.com/year-3-report.htm (accessed July 30, 2012). data brief, no 82. Hyattsville, MD: National Center 5 he New York Academy of Medicine. A Compendium T for Health Statistics, 2012. of Proven Community-Based Prevention Programs. http:// 26 Ogden CL, Carroll MD, Curtin LR, Lamb MM and www.nyam.org/news/docs/Compendium-of-Proven- Flegel KM. Prevalence of High Body Mass Index in Community-Based-Prevention-Programs.pdf (ac- US Children and Adolescents, 2007-2008. Journal of cessed August 2012). the American Medical Association. 303(3): 242-249, 2010. 6 aicker K, Cutler D and Song Z. Workplace Wellness B 27 Ibid. Programs Can Generate Savings. Health Affairs, 29, 28 Ibid. no.2 (2010):304-311. 29 Ibid. 7 gden CL, Carroll MD, Kit BK, Flegal KM.  Preva- O 30 Description of BRFSS and changes in methodology lence of Obesity in the United States, 2009-2010.  provided by CDC. NCHS data brief, no 82.  Hyattsville, MD: National 31 errill RM and Richardson JS. Validity of Self-reported M Center for Health Statistics, 2012. Height, Weight, and Body Mass Index: Findings from 8 Obesity and Cancer Risk.” National Cancer Insti- “ the National Health and Nutrition Examination Sur- tute. http://www.cancer.gov/cancertopics/fact- vey, 2001-2006. Preventing Chronic Disease, 6(4):2009. sheet/Risk/obesity (accessed June 12, 2012). http://www.cdc.gov/pcd/issues/2009/oct/08_0229. 9 Body Measurements.” U.S. Centers for Disease “ htm (accessed March 12, 2010). Control and Prevention. http://www.cdc.gov/nchs/ 32 tunkard, A. J. and T. A. Wadden, eds. Obesity: S fastats/bodymeas.htm (accessed August 2012). Theory and Therapy. Second ed. New York, NY: 10 Ogden CL, Carroll MD, Kit BK, Flegal KM. Preva- Raven Press, 1993. lence of Obesity and Trends in Body Mass Index 33 National Research Council. Diet and Health: Implica- Among US Children and Adolescents, 1999-2010. tions for Reducing Chronic Disease Risk. Washington, Journal of the American Medical Association. 2012;307(5). D.C.: National Academy Press, 1989. 11 Ibid. 34 Ibid. 12 ranks PR, Hanson W, Knowler M, et al. “Childhood F 35 Barlow, S.E. “Expert Committee Recommendations Obesity, Other Cardiovascular Risk Factors, and Regarding the Prevention, Assessment, and Treat- Premature Death.” New England Journal of Medicine, ment of Child and Adolescent Overweight and Obe- 362(6):485-93, 2010. sity: Summary Report.” Pediatrics 120, suppl 4 (2007): 13 reedman et al. “Cardiovascular Risk Factors and F S164-S192. Excess Adiposity among Overweight Children and Adolescents: The Bogalusa Heart Study.” 36 arker-Pope, T. “Watch Your Girth.” The New York P Times, May 13, 2008. 14 illiland F, Berhane K, Islam T, et al. “Obesity and G the Risk of Newly Diagnosed Asthma in School-Age 37 rganization for Economic Cooperation and De- O Children.” American Journal of Epidemiology, 158(5): velopment Health Data 2011. Obesity Updated 2012. 406-15, 2003. http://www.oecd.org/dataoecd/1/61/49716427. pdf (accessed February 29, 2012). 15 edline S, Tishler P, Schluchter M, et al. “Risk Fac- R tors for Sleep-Disordered Breathing in Children: 38 Ibid. Associations with Obesity, Race and Respiratory 39 Ibid. Problems.” American Journal of Respiratory and Critical 40 Ibid. Care Medicine, 159(5): 1527–32, 1999. 41 Ibid. 16 hitaker RC, Wright JA, Pepe MS, et al. “Predicting W 42 Trust for America’s Health and Robert Wood Johnson Obesity in Young Adulthood from Childhood and Foundation. F as in Fat: How Obesity Threatens America’s Parental Obesity.” New England Journal of Medicine, Future — 2011. http://www.tfah.org/report/88/ (ac- 337(13): 869–73, 1997. cessed July 2012). Based on data using the previous 17 Ibid. BRFSS methodology in use from 2008-2010. 114 43 National Survey of Children’s Health, 2007. Over- 66 arder W and Chang S. Childhood Obesity: Costs, M weight and Physical Activity Among Children: A Portrait Treatment Patterns, Disparities in Care, and Prevalent of States and the Nation 2009, Health Resources and Medical Conditions. Thomson Medstat Research Services Administration, Maternal and Child Health Brief, 2006. http://www.medstat.com/pdfs/child- Bureau. http://www.cdc.gov/nchs/slaits/nsch.htm hood_obesity.pdf (accessed March 22, 2010.) (accessed May 24, 2011). 67 rasande L, Liu Y, Fryer G, et al. “Effects of Child- T 44 U.S. Centers for Disease Control and Prevention. hood Obesity On Hospital Care and Costs, 1999– Youth Risk Behavior Surveillance -- United States, 2005.” Health Affairs, 28(4): w751–60, 2009. 2011. Morbidity and Mortality Weekly Report, MMWR 68 henoweth & Associates. The Economic Costs of Over- C 61(SS 4): 1-162, 2012 weight, Obesity, and Physical Inactivity among California 45 Ibid. Adults -- 2006. Oakland, CA: The California Center 46 .S. Centers for Disease Control and Prevention. U for Public Health Advocacy, 2009. “Trends in the Prevalence of Obesity, Dietary Behaviors, 69 awley J, Rizzo JA, and Haas K. “Occupation-spe- C and Weight Control Practices National YRBS: 1991- cific Absenteeism Costs Associated with Obesity and 2011.” http://www.cdc.gov/healthyyouth/yrbs/pdf/ Morbid Obesity.” Journal of Occupational and Envi- us_obesity_trend_yrbs.pdf (accessed August 2012). ronmental Medicine, 49(12):1317–24, 2007. 47 gden CL, Carroll MD, Kit BK. and Flegal KM. Preva- O 70 ates D, Succop P, Brehm B, et al. “Obesity and G lence of obesity and trends in body mass index among Presenteeism: The Impact of Body Mass Index on U.S. children and adolescents, 1999-2010. Journal of the Workplace Productivity.” Journal of Occupational and American Medical Association, 307(5): 483-490, 2012. Environmental Medicine, 50(1):39-45, 2008. 48 arker LE, Kirtland KA, Gregg EW, et al. Geographic B 71 he Robert Wood Johnson Foundation, the Ameri- T Distribution of Diagnosed Diabetes in the U.S.: A Dia- can Stroke Association, and the American Heart As- betes Belt. Am J Prev Med, 40(4):434-439, 2011. sociation. A Nation at Risk: Obesity in the United States, 49 Ibid. A Statistical Sourcebook. Dallas, TX: American Heart 50 Ogden, CL et al. Prevalence of Obesity in the Association, 2005. http://www.americanheart.org/ United States. 2009-2010. In U.S. Centers for Disease downloadable/heart/1114880987205NationAtRisk. Control and Prevention. http://www.cdc.gov/nchs/ pdf (accessed April 14, 2008). data/databriefs/db82.htm (accessed July 2012). 72 stbye T, Dement JM, and Krause KM. “Obesity O 51 “Obesity and Cancer Risk.” National Cancer Institute. and Workers’ Compensation: Results from the Duke http://www.cancer.gov/cancertopics/factsheet/Risk/ Health and Safety Surveillance System.” Archives of obesity (accessed June 12, 2012). Internal Medicine, 167(8): 766-73, 2007. 52 Wang YC et al. Health and Economic Burden of the 73 ronk NP, Martinson B, Kessler RC, et al. “The As- P Projected Obesity Trends in the USA and the UK. sociation between Work Performance and Physical The Lancet, 378, 2011. Activity, Cardiorespiratory Fitness, and Obesity.” 53 Ibid. Journal of Occupational and Environmental Medicine, 46(1):19-25, 2004. 54 ote: Hypertension and arthritis were not included N in The Lancet study, but were included in the state- 74 ldana SG and Pronk NP. “Health Promotion Pro- A by-state analysis. The methodology for determining grams, Modifiable Health Risks, and Employee Ab- potential new cases of hypertension and arthritis were senteeism.” Journal of Occupational and Environmental, calculated using the same process as used for diabe- 43(1): 36-46, 2001. tes, chronic heart disease and stroke and cancer. 75 ordian Health Solutions. Managing the Obesity Prob- G 55 Ezzati, M. Trends in national and state-level obesity lem: A Case Study with Measurable Results. Nashville, in the USA after correction for self-report bias: anal- TN: Gordian Health Solutions, 2007. ysis of health surveys. J R Soc Med. 2006 May; 99(5): 76 ang F, McDonald T, Champagne LJ, et al. “Relation- W 250–257. http://www.ncbi.nlm.nih.gov/pmc/ar- ship of Body Mass Index and Physical Activity to Health ticles/PMC1457748/ (accessed July 2012). Care Costs among Employees.” Journal of Occupational 56 Finkelstein EA, Khavjou OA, Thompson H, et al. and Environmental Medicine, 46(5): 428-36, 2004. Obesity and Severe Obesity Forecasts Through 2030. 77 urton WN, Chen CY, Schultz AB, et al. “The Eco- B Am J Prev Med, 42(6): 563-570, 2012. nomic Costs Associated with Body Mass Index in a 57 Ibid. Workplace.” Journal of Occupational and Environmen- 58 Ibid. tal Medicine, 40(9): 786-92, 1998. 59 Wang YC et al. Health and Economic Burden of the 78 Ibid. Projected Obesity Trends in the USA and the UK. 79 erger E. “Emergency Departments Shoulder Chal- B The Lancet, 378, 2011. lenges of Providing Care, Preserving Dignity for the 60 Ibid. ‘Super Obese.’” Annals of Emergency Medicine, 50(4): 443-45, 2007. 61 Cawley J and Meyerhoefer C. “The Medical Care Costs of Obesity: An Instrumental Variables Ap- 80 ezima K. “Increasing Obesity Requires New Ambu- Z proach.” Journal of Health Economics, 31(1): 219-230, lance Equipment.” The New York Times, April 8, 2008. 2012; And Finkelstein, Trogdon, Cohen, et al. “An- 81 Ibid. nual Medical Spending Attributable to Obesity”. 82 .S. Centers for Disease Control and Prevention. U 62 Finkelstein, Trogdon, Cohen, et al. “Annual Medi- National diabetes fact sheet: national estimates and cal Spending Attributable to Obesity”. general information on diabetes and prediabetes in the 63 Ibid. United States, 2011. Atlanta, GA: U.S. Department 64 Ibid. of Health and Human Services, Centers for Disease Control and Prevention, 2011. 65 Trasande L. and Chatterjee S. “The Impact of Obe- sity on Health Service Utilization and Costs in Child- 83 Ibid. hood.” Obesity, 17(9):1749–54, 2009. 84 Ibid. 115 85 .S. Centers for Disease Control and Prevention. U 105 Heart Disease and Diet. In Medline Plus, National Insti- Number of Americans with Diabetes Projected to tutes of Health. http://www.nlm.nih.gov/medlineplus/ Double or Triple by 2050. Press Release, October ency/article/002436.htm (accessed May 2012). 2010. http://www.cdc.gov/media/pressrel/2010/ 106 “High Blood Pressure,” In Mayo Clinic. http://www. r101022.html (accessed March 11, 2011). mayoclinic.com/health/high-blood-pressure/HI00062 86 .S. Centers for Disease Control and Prevention. U 107 U.S. Centers for Disease Control and Prevention. Annual Number (in Thousands) of New Cases of Di- Vital signs: prevalence, treatment, and control of agnosed Diabetes Among Adults Aged 18–79 Years, hypertension—United States, 1999-2002 and 2005- United States, 1980–2010. http://www.cdc.gov/dia- 2008. MMWR. 2011;60(4):103-8. betes/statistics/incidence/fig1.htm. 108 Kurukulasuriya LR, Stas S, Lastra G, et al. Hyper- 87 .S. Centers for Disease Control and Prevention. U tension in obesity. Medical Clinics of North America, National diabetes fact sheet: national estimates and 95(5): 903-17, 2011. general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Depart- 109 Your Guide to Lowering Blood Pressure. Bethesda, ment of Health and Human Services, Centers for MD: National Heart, Lung, and Blood Institute, Disease Control and Prevention, 2011. National Institutes of Health, 2003. 88 merican Diabetes Association. “Total Prevalence A 110 Expert Answers: Can weight loss reduce the need of Diabetes & Pre-Diabetes.” American Diabetes As- for blood pressure medication? In Mayo Clinic sociation. http://diabetes.org/diabetes-statistics/ http://www.mayoclinic.com/health/blood-pres- prevalence.jsp (accessed April 18, 2008). sure-medication/AN01496 (accessed May 2012). 89 Ibid. 111 elson DT and Zhang Y. “An Update on the Epidemiol- F ogy of Knee and Hip Osteoarthritis with a View to Pre- 90 ational Institutes of Diabetes and Digestive and N Kidney Diseases. “Do You Know the Health Risks of vention.” Arthritis and Rheumatism, 41(8):1343–55, 1998. being Overweight?” U.S. Department of Health and 112 U.S. Centers for Disease Control and Prevention. Human Services. http://win.niddk.nih.gov/publica- “NHIS Arthritis Surveillance.” U.S. Department tions/health_risks.htm (accessed April 18, 2007). of Health and Human Services. http://www.cdc. gov/arthritis/data_statistics/national_data_nhis. 91 ype 2 diabetes. In Medline Plus, National Institutes T htm#excess (accessed June 26, 2008). of Health. http://www.nlm.nih.gov/medlineplus/ ency/article/000313.htm (accessed May 2012). 113 enters for Disease Control and Prevention. Preva- C lence of Obesity Among Adults with Arthritis—United 92 Insulin Resistance and Prediabetes. In National Diabetes States, 2003-2009. MMWR, 60(16): 509-513, 2011. Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases. http://diabetes.niddk.nih. 114 Do You Know the Health Risks of Being Overweight? gov/dm/pubs/insulinresistance/ (accessed May 2012). 115 rthritis Awareness and Action. In U.S. Centers for A 93 he Diabetes Prevention Program Research Group. T Disease Control and Prevention. http://www.cdc.gov/ “The Diabetes Prevention Program.” Diabetes Care, Features/ArthritisAwareness/ (accessed May 2012). 25(12): 2165-71, 2002. 116 enters for Disease control and Prevention. State- C 94 eintrub WS et al. AHA Policy Statement: Value of W Specific Prevalence of No Leisure Time Physical Primordial and Primary Prevention for Cardiovascu- Activity Among Adults With and Without Doctor-Di- lar Disease. Circulation, 124: 967-990, 2011. agnosed Arthritis. MMWR, 60(48): 1641-1645, 2011. 95 iabetes Diet — type 2. In Medline Plus, National D 117 o You Know the Health Risks of Being Overweight? D Institutes of Health. http://www.nlm.nih.gov/medline- 118 rthritis Awareness and Action. In U.S. Centers for A plus/ency/article/007429.htm (accessed May 2012). Disease Control and Prevention. http://www.cdc.gov/ 96 o You Know the Health Risks of Being Overweight? D Features/ArthritisAwareness/ (accessed May 2012). 97 nsulin Resistance and Prediabetes. In National I 119 arner J. “Small Weight Loss Takes Big Pressure off W Diabetes Information Clearinghouse, National Institute Knee.”  WebMD Health News.  http://www.webmd. com/osteoarthritis/news/20050629/small-weight- of Diabetes and Digestive and Kidney Diseases, National loss-takes-pressure-off-knee (accessed June 26, 2008). Institutes of Health. http://diabetes.niddk.nih.gov/ dm/pubs/insulinresistance/ (accessed May 2012). 120 American Cancer Society. Cancer Facts and Figures, 2012. 98 ODAY Study Group. A Clinical Trial to Maintain T Atlanta, GA: American Cancer Society; 2012.” And also Glycemic Control in Youth with Type 2 Diabetes. please change endnote 121 to the following: “Centers for Disease Control and Prevention, (2012). Report to NEJM, 10.1056/NEJMoa1109333, 2012. the nation finds continuing declines in cancer death 99 Ibid. rates since the early 1990s: Special feature highlights 100 udwig J, Sanbonmatsu L, Gennetian L, et al. L cancers associated with excess weight and lack of suffi- Neighborhoods, Obesity, and Diabetes—A Ran- cient physical activity. [Press Release]. http://www.cdc. domized Social Experiment. The New England Jour- gov/media/releases/2012/p0328_Cancer_deathrates. nal of Medicine, 365(16): 1509-1519, 2011. html (accessed September 12, 2012). 101 Ibid. 121 http://www.cdc.gov/media/releases/2012/p0328_ 102 o You Know the Health Risks of Being Over- D Cancer_deathrates.html weight? In National Institute of Diabetes and Digestive 122 .S. Centers for Disease Control and Prevention. U and Kidney Diseases, National Institutes of Health. “Obesity in the News: Helping Clear the Confu- http://win.niddk.nih.gov/publications/health_ sion.” Power Point Presentation, May 25, 2005. risks.htm (accessed May 2012). 123 ochanek KD, Xu J, Murphy SL, et al. Deaths: K 103 eintrub WS et al. AHA Policy Statement: Value W Preliminary Data for 2009. National Vital Statistics of Primordial and Primary Prevention for Cardio- Reports, 59(4), 2011. vascular Disease. Circulation, 124: 967-990, 2011. 124 besity and Cancer Risk. In National Cancer Institute. O 104 o You Know the Health Risks of Being Over- D http://www.cancer.gov/cancertopics/factsheet/ weight? In National Institute of Diabetes and Digestive Risk/obesity (accessed June 6, 2012). and Kidney Diseases, National Institutes of Health. 125 International Agency for Research on Cancer. Weight http://win.niddk.nih.gov/publications/health_ Control and Physical Activity Volume 6. IARCPress, 2002. 116 risks.htm (accessed May 2012). 126 hysical Activity and Cancer. In National Cancer Insti- P 147 Ibid. tute. http://www.cancer.gov/cancertopics/factsheet/ 148 arker-Pope T. “Timing of Baby Food Tied to Obesity P prevention/physicalactivity (accessed June 6, 2012). Risk.” The New York Times February 8, 2011. http:// 127 Friedenreich CM et al. “Inflammatory marker well.blogs.nytimes.com/2011/02/08/timing-of-baby- changes in a yearlong randomized exercise in- food-tied-to-obesity-risk/ (accessed April 12, 2012). tervention trial among postmenopausal women.” 149 Ibid. Cancer Prev Res (Phila). 2012 Jan;5(1):98-108. Epub 150 Ibid. 2011 Oct 7. http://www.aicr.org/press/press- releases/getting-up-from-your-desk.html 151 Ibid. 128 wen N, Sugiyama T, Eakin EE, et al. Adults’ Seden- O 152 nited States Breastfeeding Committee, (2010). U Preventing Obeisty Begins at Birth through Breast- tary Behavior: Determinants and Interventions. Ameri- feeding.” [Press Release]. http://www.usbreast- can Journal of Preventive Medicine, 41(2): 189-196, 2011. feeding.org/NewsInfo/NewsRoom/201002Preven 129 hysical Activity and Cancer. In National Cancer Insti- P tingObesityBeginsatBirth/tabid/169/Default.aspx tute. http://www.cancer.gov/cancertopics/factsheet/ (accessed April 16, 2012). prevention/physicalactivity (accessed June 6, 2012). 153 reastfeeding Among U.S. Children Born 2000— B 130 American Cancer Society Guidelines for Nutrition 2008, CDC National Immunization Survey. In U.S. and Physical Activity to Prevent Cancer. http:// Centers for Disease Control and Prevention. http:// www.cancer.org/acs/groups/cid/documents/ www.cdc.gov/breastfeeding/data/NIS_data/index. webcontent/002577-pdf.pdf (accessed June 2012). htm (accessed April 16, 2012). 131 Campbell KL, Foster-Schubert KE, Alfano CM, et 154 nited States Breastfeeding Committee, (2010). Pre- U al. Reduced-Calorie Dietary Weight Loss, Exercise, venting Obeisty Begins at Birth through Breastfeeding.” and Sex Hormones in Postmenopausal Women: [Press Release]. http://www.usbreastfeeding.org/News- Randomized Controlled Trial. Journal of Clinical Info/NewsRoom/201002PreventingObesityBeginsatBi Oncology, doi: 10.1200/JCO.2011.37.9792, 2012. rth/tabid/169/Default.aspx (accessed April 16, 2012). 132 Ibid. 155 .S. Department of Health and Human Services. The U 133 ey T, Appleby P, Barnes I, et al. Endogenous K Surgeon General’s Call to Action to Support Breastfeeding. Hormones and Breast Cancer Collaborative Group: Washington, DC: U.S. Department of Health and Endogenous sex hormones and breast cancer in Human Services, Office of the Surgeon General; 2011. postmenopausal women: Reanalysis of nine prospec- 156 Ibid. tive studies. J Natl Cancer Inst, 94: 606-616, 2002. 157 Ibid. 134 Campbell KL, Foster-Schubert KE, Alfano CM, et 158 eydoun et al. “Obesity and Central Obesity as Risk B al. Reduced-Calorie Dietary Weight Loss, Exercise, Factors for Incident Dementia and Its Subtypes”. and Sex Hormones in Postmenopausal Women: 159 etry et al. “Overweight and Obesity Are Associated P Randomized Control Study. Journal of Clinical On- with Psychiatric Disorders”. cology, doi: 10.1200/JCO.2011.37.9792, 2012. 160 Ibid. 135 Trust for America’s Health. Healthy Women: The 161 hitmer RA, Gustafson DR, Barrett-Connor E, W Path to Healthy Babies: The Case for Preconception et al. Central obesity and increased risk of de- Care. Washington, D.C.: TFAH, 2008. mentia more than three decades later. Neurology. 136 U.S. Centers for Disease Control and Prevention. 71(14):1057-64, 2008. “Maternal and Infant Health Research: Pregnancy 162 oon DH, Choi SH, Yu JG, et al. The relation- Y Complications.” http://www.cdc.gov/reproduc- ship between visceral adiposity and cognitive tivehealth/maternalinfanthealth/PregComplica- tions.htm#obesity (accessed March 10, 2011). performance in older adults. Age and Ageing, doi: 10.1093/ageing/afs018, 2012. 137 U.S. Centers for Disease Control and Prevention. “Recommendations to Improve Preconception 163 u WL, Atti AR, Gatz M, et al. Midlife overweight X and obesity increase late-life dementia risk: a Health and Health Care--United States.” Morbidity population-based twin study. Neurology, 76(18): and Mortality Weekly Report, 55(4): RR-6, 2006. 1568-1574, 2011. 138 aeri S, Guichard I, Baker AM, et al. “The Effect of H 164 Rolland, Y et al. “Physical Activity and Alzheimer’s Dis- Teenage Maternal Obesity on Perinatal Outcomes.” ease: From Prevention to Therapeutic Perspectives.” Obstetrics & Gynecology, 113(2): 300-4, 2009. JAMDA. DOI: 10.1016/j.jamda.2008.02.007 and Buch- 139 Chu SY, Bachman DJ, Callaghan WM, et al. “Asso- man AS et al. Total daily physical activity and the risk ciation between Obesity during Pregnancy and In- of AD and cognitive decline in older adults. Neurol- creased Use of Health Care.” New England Journal ogy. 2012 Apr 24;78(17):1323-9. Epub 2012 Apr 18. of Medicine, 358(14): 1444-53, 2008. 165 reventing Alzheimer’s: Exercise is Still Best. In Mayo P 140 Ibid. Clinic Alzheimer’s Blog, 2008. 141 U.S. Centers for Disease Control and Prevention. 166 runner EJ, Marmot MG, Nanchahal K, et al. So- B Does Breastfeeding Reduce the Risk of Pediatric cial inequality in coronary risk: central obesity and Overweight? Research to Practice Series (4): 2007. the metabolic syndrome. Evidence from the White- 142 U.S. Centers for Disease Control and Prevention. hall II study. Diabetologia, 40(11): 1341-49, 1997. Breastfeeding Report Card -- United States, 2010. At- 167 aubenmier J, Kristeller J, Hecht FM, et al. Mind- D lanta, GA: CDC, 2010. fulness Intervention for Stress Eating to Reduce 143 Ip S, Chung M, Raman G, et al. Breastfeeding and Cortisol and Abdominal Fat among Overweight Maternal and Infant Health Outcomes in Developed and Obese Women: An Exploratory Randomized Countries. Rockville, MD: Agency for Healthcare Controlled Study. Journal of Obesity, 2011. Research and Quality, 2007. 168 Ibid. 144 oreno MA. Breastfeeding as Obesity Prevention. Ar- M 169 atson NF, Harden KP, Buchwald D, et al. Sleep W chives of Pediatrics & Adolescent Medicine, 165(8): 2011. Duration and Body Mass Index in Twins: A Gene- 145 Ibid. Environment Interaction. Journal Sleep, doi. 146 Ibid. org/10.5665/sleep.1810, 2012. 117 170 Ibid. 192 O’Brien KS, Hunter JA, and Banks M. “Implicit 171 Ibid. Anti-Fat Bias in Physical Educators: Physical At- 172 ang et al. “Association between Obesity and Kid- W tributes, Ideology, and Socialisation.” International ney Disease”. Journal of Obesity, 31(2): 308-14, 2007. 173 Ibid. 193 Stunkard AJ, Faith MS, and Allison KC. “Depression and Obesity.” Biological Psychiatry, 54(3): 330-7, 2003. 174 ational Digestive Diseases Information Clearing- N house (NDDIC). “Nonalcoholic Steatohepatitis.” 194 Carr D and Friedman MA. “Is Obesity Stigmatiz- http://digestive.niddk.nih.gov/ddiseases/pubs/ ing? Body Weight, Perceived Discrimination, and nash/ (accessed March 12, 2010). Psychological Well-Being in the United States.” Jour- 175 Ibid. nal of Health and Social Behavior, 46(3): 244-59, 2005. 176 rum-Cianflone NF, Roediger M, Eberly LE, et al. C 195 Annis NM, Cash TF, and Hrabosky JI. “Body “Obesity among HIV-infected Persons: Impact of Image and Psychosocial Differences among Stable Weight on CD4 Cell Count.” AIDS (epub ahead of Average Weight, Currently Overweight, and For- print): 2010. merly Overweight Women: the Role of Stigmatiz- ing Experiences.” Body Image, 1(2): 155-67, 2004. 177 ndreyeva T, Puhl RM, and Brownell KD. A “Changes in Perceived Weight Discrimination 196 Puhl RM, Moss-Racusin CA, and Schwartz MB. “Inter- among Americans: 1995-1996 through 2004-2006.” nalization of Weight Bias: Implications for Binge Eating Obesity, 16(5):1129-34, 2008. and Emotional Well-Being.” Obesity, 15(1): 19-23, 2007. 178 uhl RM, Adnreyeva T, and Brownell KD. “Percep- P 197 Rosenberger PH, Henderson KE, and Grilo CM. tions of Weight Discrimination: Prevalence and “Correlates of Body Image Dissatisfaction in Ex- Comparison to Race and Gender Discrimination tremely Obese Female Bariatric Surgery Candi- in America.” International Journal of Obesity, 32(6): dates.” Obesity Surgery, 16(10): 1331-6, 2006. 992-1000, 2008. 198 Matthews KA, Salomon K, Kenyon K, et al. “Unfair 179 uhl RM and Heuer CA. Obesity Stigma: Impor- P Treatment, Discrimination, and Ambulatory Blood tant Considerations for Public Health. Am J Public Pressure in Black and White Adolescents.” Health Health, 100: 1019-1028, 2010. Psychology, 24(3): 258-65, 2005. 180 uhl RM and Heuer CA. “The Stigma of Obesity: P 199 Kung HC, Hoyert DL, Xu JQ, and Murphy SL. Deaths: A Review and Update.” Obesity, 17(5): 941-64, 2009. final data for 2005. National Vital Statistics Reports 2008. Atlanta, GA: Centers for Disease Control and Preven- 181 Puhl RM and Brownell KD. “Confronting and Coping tion, 2008. http://www.cdc.gov/nchs/data/nvsr/ with Weight Stigma: An Investigation of Overweight nvsr56/nvsr56_10.pdf (accessed July 14, 2010). and Obese Adults.” Obesity, 14(10): 1802-15, 2006. 200 Veugelers PJ and Fitzgerald AL. Effectiveness of 182 Roehling MV, Roehling PV, and Pichler S. “The School Programs in Preventing Childhood Obesity: Relationship between Body Weight and Perceived A Multilevel Comparison. American Journal of Public Weight-Related Employment Discrimination: The Health, 95(3): 432-35, 2005. Role of Sex and Race.” Journal of Vocational Behavior, 71(2): 300-18, 2007. 201 New Mexico Legislature, http://www.nmlegis.gov/ Sessions/07%20Regular/final/HB0208.pdf (ac- 183 Pingitore R, Dugoni R, Tindale S, et al. “Bias cessed May 24, 2011). against Overweight Job Applicants in a Simulated Employment Interview.” Journal of Applied Psychology, 202 Ibid. 79(6): 909-17, 1994. 203 Why Salad Bars? In Let’s Move Salad Bars to Schools. 184 aum CL and Ford WF. “The Wage Effects of B http://saladbars2schools.org/why (accessed April Obesity: A Longitudinal Study.” Health Economics, 3, 2012). 13(9):885-99, 2004. 204 Ibid. 185 oster GD, Wadden TA, Makris AP, et al. “Primary F 205 Hudson W. “For Schoolchildren, Where’s the Care Physicians’ Attitudes about Obesity and Its Water?” CNN April 18, 2011. http://www.cnn. Treatment.” Obesity Research, 11(10): 1168-77, 2003. com/2011/HEALTH/04/18/water.school.chil- 186 rown I. “Nurses’ Attitudes towards Adult Patients B dren/ (accessed April 18, 2011). Who Are Obese: Literature Review.” Journal of Ad- 206 Ibid. vanced Nursing, 53(2): 221-32, 2006. 207 Ibid. 187 ear D, Aultman JM, Varley JD, et al. “Making W 208 Hudson W. “For Schoolchildren, Where’s the Fun of Patients: Medical Students’ Perceptions and Water?” CNN April 18, 2011. http://www.cnn. Use of Derogatory and Cynical Humor in Clinical com/2011/HEALTH/04/18/water.school.chil- Settings.” Academic Medicine, 81(5): 454-62, 2006. dren/ (accessed April 18, 2011). 188 hambliss HO, Finley CE, and Blair SN. “Attitudes C 209 Ibid. towards Obese Individuals among Exercise Science 210 Ibid. Students.” Medicine and Science in Sports and Exercise, 211 Patel AI, Bogart LM, Elliot MN, et al. Increasing 36(3): 468-74, 2004. the Availability and Consumption of Drinking 189 arvey EL, Summerbell CD, Kirk SF, et al. “Di- H Water in Middle Schools: A Pilot Study. Preventing etitians’ Views of Overweight and Obese People Chronic Disease, 8(3): 1-9, 2011. with Reported Management Practices.” Journal of 212 Ibid. Human Nutrition and Dietetics, 15(5): 331-47, 2002. 213 Ibid. 190 uhl RM, Peterson JL, Luedicke J. Parental P 214 Ibid. Perceptions of Weight Terminology That Provid- ers Use With Youth. Pediatrics, DOI: 10.1542/ 215 U.S. Government Accountability Office. School Meal peds.2010-3841, 2011. Programs: Competitive Foods Are Available in Many 191 eumark-Sztainer D, Story M, and Harris T. “Beliefs N Schools; Actions Taken to Restrict Them Differ by State and Attitudes about Obesity among Teachers and and Locality. Washington, D.C.: U.S. Government School Health Care Providers Working with Adoles- Accountability Office, 2004. http://www.gao.gov/ cents.” Journal of Nutrition Education, 31(1): 3-9, 1999. new.items/d04673.pdf (accessed May 21, 2009). 118 216 Ibid, p. 2. 240 Chaddock L, Erickson EI, Prakash RS, et al. Basal Gan- 217 Ibid, p. 12. glia Volume is Associated with Aerobic Fitness in Pre- 218 ids’ Safe & Healthful Foods Project, (2012). Poll K adolescent Children. Dev Neurosci, 32(3): 249-56, 2010. shows strong voter support for nutrition standards for 241 Ibid. food and beverages sold in school vending machines 242 ampey B, Dion G, and Donahue P. NAEP 2008 R and a la carte lines: Finds come as USDA prepares to Trends in Academic Progress. Washington, D.C., U.S. release proposed standards. [Press Release]. http:// Department of Education, 2008. www.rwjf.org/files/research/kshfsurveysnacksandbev- 243 he Association Between School-Based Physical Activity, T eragesapril2012.pdf (accessed May 10, 2012). Including Physical Education, and Academic Perfor- 221 Kids’ Safe & Healthful Foods Project and Health mance. Atlanta, GA: U.S. Department of Health Impact Project. Health Impact Assessment: National and Human Services, 2010. Nutrition Standards for Snack and a la Carte Foods 244 elk G. Cardiovascular Fitness and Body Mass Index W and Beverages Sold in Schools. Robert Wood Johnson are Associated with Academic Achievement in Schools. Foundation and PEW Health Group, 2012. Dallas, Texas: Cooper Institute, March 2009. 222 Ibid. 245 merican Academy of Pediatrics. “Policy Statement: A 223 Joshi A., Kalb M, Beery M. Going Local: Paths to Suc- Prevention of Pediatric Overweight and Obesity.” Pe- cess for Farm to School Programs. Los Angeles: Occiden- diatrics 112, no. 2 (2003):424-430 and Murray, R. “Re- tal College and Community Food Security Coalition, sponse to ‘Parents’ Perceptions of Curricular Issues 2006. http://departments.oxy.edu/uepi/cfj/publi- Affecting Children’s Weight in Elementary Schools.’” cations/goinglocal.pdf (accessed March 19, 2009). Journal of School Health 77, no. 5 (2007):223. 224 Ibid. 246 Institute of Medicine, Preventing Childhood Obesity. 225 Upstream Public Health. HB 2800: Oregon Farm to 247 erger M, Konty K, Day S, et al. Obesity in K-8 Stu- B School and School Garden Policy. May 2011. http:// dents—New York City, 2006-07 to 2010-11 School www.upstreampublichealth.org/F2SHIA (accessed Years. Morbidity and Mortality Weekly Report, 60(49): August 24, 2012). 1673-1678, 2011. 226 Hawkins B. “’Farm to School’: Moving from pink 248 Ibid. slime to purple beets.” Minnpost March 22, 2012. 249 Ibid. 227 “Free teen gardening workshop starts May 1.” The 250 Ibid. Herald-Tribune March 28, 2012. 251 Ibid. 228 Fitz Simons J. “Farms on Wheels Brings Agricul- 252 aughlin L. Who’s minding the Kids? Child care ar- L ture to Schools.” San Diego Reader March 26, 2012. rangements: Spring 2005/summer 2006. Washington, 229 ohnston LD, O’Malley PM, Terry-McElrath YM, & J D.C.: Current Population Reports, U.S. Census Colabianchi N. School policies and practices to improve Bureau, 2010. health and prevent obesity: National secondary school survey 253 abor V and Mantinan K. State Efforts to Address G results, school years 2006–07 through 2009 –10. Volume 2. Obesity Prevention in Child Care Quality Rating and Bridging the Gap Program, Survey Research Center, Institute for Social Research, Ann Arbor, MI, 2012. Improvement Systems. Washington, D.C.: Altarum Insistute, 2012. 230 U.S. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 254 Ibid. 2011. Morbidity and Mortality Weekly Report, MMWR 255 Ibid. 61(SS 4): 1-162, 2012. 256 Ibid. 231 Mahar MT, Murphy SK, Rowe DA, et al. Effects of 257 aters E, de Silva-Sanigorski A, Hall BJ, et al. Inter- W a classroom-based program on physical activity and ventions for preventing obesity in children. Cochrane on-task behavior. Medicine and Science in Sport and Database of Systematic Reviews, 12, 2011. Exercise, 38(12): 2086-94, 2006. 258 Ibid. 232 Ibid. 259 Ibid. 233 Ibid. 260 ang YC, Orleans CT and Gortmaker SL. Reach- W 234 Kelder SH, Sringer AS, Barroso CS, et al. Imple- ing the Healthy People Goals for Reducing Child- mentation of Texas Senate Bill 19 to increase phys- hood Obesity: Closing the Energy Gap. Am J Prev ical activity in elementary school. Journal of Public Med, doi: 10.1016/j.amepre.2012.01.018, 2012. Health Policy, 30: S221-247, 2009. 261 Ibid. 235 urner L and Chalouka FJ. Activity Breaks: A Promising T 262 Ibid. Strategy for Keeping Children Physically Active at School—A 263 Ibid. BTG Research Brief. Chicago, IL: Bridging the Gap 264 Ibid. Program, Health Policy Center, Institute for Health Re- search and Policy, University of Illinois at Chicago, 2012. 265 or more information, see Chriqui et al., Local Well- F 236 Ibid. ness Policies: Assessing School District Strategies for Improv- ing Children’s Health. School Years 2006-07 and 2007-08. 237 American Association of Health Education. Compre- Chicago, IL: Bridging the Gap Program, Health hensive School Health Education: A Position Statement Policy Center, Institute for Health Research and Pol- of the American Association of Health Education, 2003. icy, University of Illinois at Chicago, 2009. Available: 238 U.S. Centers for Disease Control and Prevention. http://www.bridgingthegapresearch.org/. “SHPPS 2006: Health Education.” http://www.cdc.gov/ 266 Ibid. healthyyouth/shpps/2006/factsheets/pdf/FS_Heal- thEducation_SHPPS2006.pdf (accessed May 21, 2009). 267 ridging the Gap Program, Institute for Health Re- B search and Policy, University of Illinois at Chicago, 239 U.S. Centers for Disease Control and Prevention. 2012. Available at: www.bridgingthegapresearch.org. The Association Between School Based Physical Activity, 268 acobson MH and Brownell KD. Small Taxes on J Including Physical Education, and Academic Perfor- Soft Drinks and Snack Foods to Promote Health. mance. Atlanta, GA: U.S. Department of Health and American Journal of Public Health, 90(6): 854-57, 2000. Human Services; 2010. 119 269 ongressional Budget Office. Health Care Budget C 286 Ibid. Options, Volume 1. Washington, D.C.: U.S. Con- 287 owell KE, Martin L, Chowdhury PP. Places to Walk: P gress, 2008, p. 206. Convenience and Regular Physical Activity. Ameri- 270 Brownell KD, Kersh R, Ludwig DS, et al. Personal Re- can Journal of Public Health, 93(9):1519-21, 2003. sponsibility and Obesity: A Constructive Approach to a 288 Giles-Corti B and Donovan RJ. The Relative Influ- Controversial Issue. Health Affairs, 29(3): 379-87, 2010. ence of Individual, Social, and Physical Environ- 271 rown PL. “Plan to Tax Soda Gets a Mixed Recep- B ment Determinants of Physical Activity. Social tion.” NY Times June 2, 2012. http://www.nytimes. Science & Medicine, 54(12):1793-1812, 2002. com/2012/06/03/us/richmond-calif-seeks-to-tax- 289 Robert Wood Johnson Foundation (RWJF). Grant Re- sweetened-beverages.html (accessed August 24, 2012). sults: Researchers Review State Policies on Promoting Walking 272 llen, S. “Proposed El Monte soda tax draws criti- A and Biking - Identify Five with Greatest Potential to Work. cism.” Los Angeles Times. July 26, 2012. http:// Princeton, NJ: RWJF, 2005, http://www.rwjf.org/re- articles.latimes.com/2012/jul/26/local/la-me- ports/grr/046958.htm (accessed April 10, 2008). soda-tax-20120726 (August 27, 2012). 290 Wendy L. Johnson-Askew et al., “Decision Mak- 273 rown PL. “Plan to Tax Soda Gets a Mixed Recep- B ing in Eating Behavior: State of the Science and tion.” NY Times June 2, 2012. http://www.nytimes. Recommendations for Future Research,” Annals of com/2012/06/03/us/richmond-calif-seeks-to-tax- Behavioral Medicine 38, Suppl. (2009). sweetened-beverages.html (accessed August 24, 2012). 291 he National Academies, “Food Marketing Aimed T 274 artanian LR, Schwartz MB, Brownell KD. Effects V at Kids Influences Poor Nutritional Choices, IOM of soft drink consumption on nutrition and health: Study Finds; Broad Effort Needed to Promote a systematic review and meta-analysis. Am J Public Healthier Products and Diets,” press release, 6 Dec. Health, 97:667-675, 2007. 2005, www8.nationalacademies.org/onpinews/news- 275 chulze MB, Manson JE, Ludwig DS, et al. Sugar- S item.aspx?RecordID=11514 (viewed 26 Mar. 2007). sweetened beverages, weight gain, and incidence 292 Montgomery K and Chester J. Digital Food Marketing of type 2 diabetes in young and middle-aged to Children and Adolescents: Problematic Practices and Pol- women. JAMA, 292: 927-934, 2004. icy Interventions. National Policy & Legal Analysis Net- 276 ung TT, Malik V, Rexrode KM, et al. Sweetened F work to Prevent Childhood Obesity, October 2011. beverage consumption and risk of coronary heart dis- 293 Ibid. ease in women. Am J Clin Nutr, 89: 1037-1042, 2009. 294 Polacsek M, O’Rourke K, O’Brian L, Blum JW, Dona- 277 chulze MB, Manson JE, Ludwig DS, et al. Sugar- S hue S. Examining Compliance With a Statewide Law sweetened beverages, weight gain, and incidence Banning Food and Beverage Marketing in Maine of type 2 diabetes in young and middle-aged Schools. Public Health Reports, 127: 216-223, 2012. women. JAMA, 292: 927-934, 2004. 295 Polacsek M, O’Rourke K, O’Brian L, Blum JW, Dona- 278 ung TT, Malik V, Rexrode KM, et al. Sweetened F hue S. Examining Compliance With a Statewide Law beverage consumption and risk of coronary heart dis- Banning Food and Beverage Marketing in Maine ease in women. Am J Clin Nutr, 89: 1037-1042, 2009. Schools. Public Health Reports, 127: 216-223, 2012. 279 attes RD, Popkin B. Nonnutritive sweetener con- M 296 Ibid. sumption in humans: effects on appetite and food 297 Ibid. intake and their putative mechanisms. AM J Clin 298 Ibid. Nutr, 89: 1-14, 2009. 299 Robert Wood Johnson Foundation and PEW 280 he American Medical Association. “AMA Adopts T Health Group. “Health Impact Assessment: Na- Policies to Promote Healthier Food Options to tional Nutrition Standards for Snack and a la Carte Fight Obesity in America.” News Release June 27, Foods and Beverages.” June 2012. http://www. 2007. http://www.ama-assn.org/ama/pub/cat- rwjf.org/childhoodobesity/product.jsp?id=74532 egory/17768.html (accessed May 27, 2008). (accessed August 2012). 281 udd Center for Food Policy and Obesity. “Menu R 300 A Compendium of Proven Community-Based Prevention Labeling Laws.” http://yaleruddcenter.org/what_ we_do.aspx?id=124 (accessed March 26, 2009). Programs. New York, NY: The New York Academy of Medicine, 2009. 282 Walmart, (2012). Walmart Unveils “Great For You’ Icon: Icon to appear on hundreds of food items and 301 Community Guide to Preventive Services. U.S. Centers provide simple way to make healthier food choices; for Disease Control and Prevention, 2011. http:// Update on progress made over past year. [Press Re- www.thecommunityguide.org/index.html (ac- lease]. http://www.walmartstores.com/pressroom/ cessed January 17, 2012). news/10818.aspx (accessed April 12, 2012). 302 MCA, (2012). YMCA’s Diabetes Prevention Program Y 283 ational Restaurant Association. “House Vote to N Results Show Group Behavior Changes Can Improve Prevent Frivolous Lawsuits against Restaurants, Individual Health and Potentially Save Billions in Fu- Food Manufacturers: Just Plain Common Sense.” ture Health Care Costs. [Press Release]. http://www. Press Release, March 10, 2004. http://www.res- ymca.net/news-releases/20120530-diabetes-preven- taurant.org/pressroom/print/index.cfm?ID=833 tion-results.html (accessed August 24, 2012). (accessed April 25, 2008). 303 YMCA Press Release. “26,749 Changes Impact Up 284 .S. Centers for Disease Control and Prevention U to 46 Million Lives: YMCA of the USA’s Healthier (CDC). Barriers to Children Walking and Biking to Communities Initiatives (HCI).” School--United States, 1999. Morbidity and Mortality 304 Ibid. Weekly Report, 51(32):701-4, 2002. 305 Ibid. 285 ational Center for Safe Routes to School and N 306 Ibid. Safe Routes to School National Partnership. “U.S. 307 Frequently Asked Questions about Small Business. Travel Data Show Decline In Walking And Bicy- In Small Business Administration. http://www.sba.gov/ cling To School Has Stabilized.” Press Release, sites/default/files/sbfaq.pdf (accessed May 2012). April 8, 2010. http://www.saferoutespartner- ship.org/media/file/NHTS-SRTS-Press-Re- 120 lease-04082010.pdf (accessed April 9, 2010). 308 laxton G, Rae M, Panchal M, et al. Employer Health C 331 ational Prevention Council. National Prevention N Benefits 2011 Annual Survey. Menlo Park Califor- Council Action Plan: Implementing the National Pre- nia, Chicago: Kaiser Family Foundation, Health vention Strategy. U.S. Department of Health and Research and Educational Trust and the National Human Services. June 2012. Opinion Research Center, 2011. 332 aciosek, MV, et al. “Greater Use Of Preventive M 309 Small Business Administration. “What is SBA’s Services In U.S. Health Care Could Save Lives At definition of a small business concern.” http:// Little Or No Cost.” Health Affairs. 29, NO. 9 (2010): www.sba.gov/content/what-sbas-definition-small- 1656–1660; U.S. Centers for Disease Control and business-concern (accessed August 2012). Prevention, Administration on Aging, Agency for 310 rust for America’s Health and Small Business Major- T Healthcare Research and Quality, and Centers for ity. “Striving for a Healthier America Through Avail- Medicare and Medicaid Services. Enhancing Use of ability and Uptake of Workplace Wellness Programs Clinical Preventive Services Among Older Adults. in the Small Business Community.” December 2011. Washington, DC: AARP, 2011; Institute of Medicine. 311 Comprehensive Workplace Health Programs to Ad- “Preventive Services for Women.” July 2011. dress Physical Activity, Nutrition, and Tobacco Use in 333 lickman D, Parker L, Sim LJ, et al. Accelerating Prog- G the Workplace. In U.S. Centers for Disease Control and ress in Obesity Prevention: Solving the Weight of the Nation. Prevention. http://www.cdc.gov/workplacehealthpro- Washington, D.C.: The National Academies, 2012. motion/nhwp/index.html (accessed May 2012). 334 Ibid. 312 laxton G, Rae M, Panchal M, et al. Employer Health C 335 Ibid. Benefits 2011 Annual Survey. Menlo Park Califor- 336 ipartisan Policy Center. Lots to Lose: How America’s B nia, Chicago: Kaiser Family Foundation, Health Health and Obesity Crisis Threatens our Economic Future. Research and Educational Trust and the National Washington, D.C.: Bipartisan Policy Center, 2012. Opinion Research Center, 2011. 337 .S. Department of Health and Human Services, U 313 Ibid. Public Health Service, Centers for Disease Control 314 mall Employer Qualified Wellness Program Tax S and Prevention, National Center for Chronic Dis- Credit. In Indiana State Department of Health. http:// ease Prevention and Health Promotion, and Divi- www.state.in.us/isdh/25139.htm (accessed April 2012). sion of Nutrition and Physical Activity. Promoting 315 aicker K, Cutler D, Song Z. Workplace wellness B Physical Activity: A Guide for Community Action. Vol. programs can generate savings. Health Affairs, 1. Champaign, IL: Human Kinetics, 1999. 29(2): 304-11. 2010. 338 .S. Centers for Disease Control and Prevention. “U.S. U 316 reater Washington’s Healthiest Employers. In Wash- G Physical Activity Statistics: Summary of Physical Activ- ington Business Journal. http://www.bizjournals.com/ ity, 2008.” http://apps.nccd.cdc.gov/PASurveillance/ washington/event/38641 (accessed April 2012). StateSumResultV.asp (accessed March 22, 2010). 317 eam M, Ehrlich G, Black JD, et al. Evaluation of B 339 arnes PM, Ward BW, Freeman G, Schiller JS. B the Healthy Schools Program: Part I. Interim Prog- Early release of selected estimates based on data ress. Prev Chronic Dis, 9, 2012. from the Jan-Sept 2011 National Health Interview Survey. National Center for Health Statistics, 318 Ibid. March 2012. 319 Ibid. 340 enters for Disease Control and Prevention. Youth C 320 uccess Stories. In Alliance for a Healthier Generation. S Risk Behavior Surveillance—United States, 2011. https://schools.healthiergeneration.org/resources__ MMWR, 61(SS-4), 2012. tools/success_stories/ (accessed April 9, 2012). 341 .S. Centers for Disease Control and Prevention. “U.S. U 321 Ibid. Physical Activity Statistics: Summary of Physical Activ- 322 Ibid. ity, 2008.” http://apps.nccd.cdc.gov/PASurveillance/ 323 Ibid. StateSumResultV.asp (accessed March 22, 2010). 324 Ibid. 342 .S. Centers for Disease Control and Prevention. U 325 ational Association of School Nurses (2011). Role N “U.S. Physical Activity Statistics: All States: Recom- of the school nurse (Position Statement). mended Physical Activity by: Race.” http://apps. nccd.cdc.gov/PASurveillance/DemoCompareRe- 326 ational Association of School Nurses. (2011). N sultV.asp?State=0&Cat=4&Year=2008&Go=GO (ac- Overweight and Obesity in Youth in Schools - The cessed March 22, 2010). Role of the School Nurse (Position Statement). Retrieved from http://www.nasn.org/PolicyAdvo- 343 ee IM, Djoussé L, Sesso HD, et al. “Physical Ac- L cacy/PositionPapersandReports/NASNPosition- tivity and Weight Gain Prevention.” Journal of the Statemen tsFullView/tabid/462/ArticleId/39/ American Medical Association, 303(12): 1173-79, 2010. Overweight-and-Obesity-in-Youth-in-Schools-The- 344 ee IM, Djoussé L, Sesso HD, et al. “Physical Activ- L Role-of-the-School-Nurse-Revised-2011 ity and Weight Gain Prevention.” Journal of the Amer- 327 Adjusted for inflation. ican Medical Association, 303(12): 1173-79, 2010. 328 rust for America’s Health. Investing in America’s T 345   legal KM,  Carroll MD, Ogden CL, Curtin LR.  F Health: A State-By-State Look at Public Health Funding Prevalence and Trends in Obesity Among US and Key Health Facts. March 2012. http://www. Adults, 1999-2008.  JAMA, 303(3):235-241, 2010.  tfah.org/report/94/ (accessed August 2012). 346 tessman J, Hammerman-Rozenberg R, Cohen A, S 329 udget Cuts Continue to Affect the Health of Americans: Up- B et al. “Physical Activity, Function, and Longevity date November 2011. Washington, D.C.: Association of among the Very Old.” Archives of Internal Medicine, State and Territorial Health Officials, November 2011. 169(16):1476-83, 2009. 330 esearch America! Sequestration: Health Research at the Break- R 347 nderson LH, Martinson BC, Crain AL, et al. A ing Point. http://www.researchamerica.org/uploads/ “Health Care Charges Associated with Physical RASequestrationReport.pdf (accessed August 2012) Inactivity, Overweight, and Obesity.” Preventing Chronic Disease, 2(4): A09, 2005. 121 348 ee DC, Sui X, and Blair SN. “Does Physical Activ- L 365 Vanderbilt T.  The Crisis in American Walking: ity Ameliorate the Health Hazards of Obesity?” Brit- How we got off the pedestrian path.  Slate.com April ish Journal of Sports Medicine, 43(1): 49-51, 2009. 10, 2012.  http://www.slate.com/articles/life/walk- 349 effrey RW and Utter J. “The Changing Envi- J ing/2012/04/why_don_t_americans_walk_more_ ronment and Population Obesity in the United the_crisis_of_pedestrianism_.html  (accessed April States.” Obesity Research, 11(Suppl): 12S-22S, 2003. 11, 2012).  And Duncan MJ, Al-Nakeeb Y, Wood- field L, Lyons M.  Pedometer determined physical 350 oss R, and Janssen I. “Physical Activity, Fitness, R activity levels in primary school children from cen- and Obesity.” Chap. 11, In Physical Activity and tral England.  Prev Med, 44(5): 416-420, 2007. Health, edited by Bouchard C, Blair SN and Haskell WL. 1st ed. Vol. 1, 173-189. Champaign, IL: 366 Bassett DR, Schneider PL and Huntington GE.  Phys- Human Kinetics, 2007. ical Activity in an Older Amish Community.  Medicine and Science in Sports and Exercise, 36(1): 79-85, 2004. 351 edley, Ogden, Johnson, et al. “Prevalence of H Overweight and Obesity among U.S. Children, 367 Santos A, McGuckin N, Nakamoto HY, et al. Sum- Adolescents, and Adults; 1999-2002.” mary of Travel rends: 2009 National Household Travel 352 askell W L, Blair SN, and Bouchard C. “An H Survey. Washington, D.C.: U.S. Department of Integrated View of Physical Activity, Fitness and Transportation, 2011. Health.” Chap. 23, In Physical Activity and Health, ed- 368 Vanderbilt T. The Crisis in American Walking: How ited by Bouchard C, Blair SN and Haskell WL. Vol. we got off the pedestrian path. Slate.com April 10, 2012. 1, 359-374. Champaign, IL: Human Kinetics, 2007. http://www.slate.com/articles/life/walking/2012/04/ 353 .S. Centers for Disease Control and Prevention. U why_don_t_americans_walk_more_the_crisis_of_pe- “Youth Risk Behavior Surveillance — United destrianism_.html (accessed April 11, 2012). States, 2007.” Morbidity and Mortality Weekly Re- 369 Ibid. port, 57(SS-4): 2008. 370 Ibid. 354 .S. Centers for Disease Control and Prevention. U 371 Ibid. “Physical Activity Levels among Children Aged 372 Ibid. 9-13years — United States, 2002.” Morbidity and 373 U.S. Department of Health and Human Services. Mortality Weekly Report, 52(33):785, 2003. 2008 Physical Activity Guidelines for Americans. 355 roiano R, Berrigan D, Dodd K, et al. “Physical Activity T Washington, D.C.: U.S. Department of Health and in the United States Measured by Accelerometer.” Med- Human Services, 2008. icine & Science in Sports & Exercise, 40(1): 181-8, 2008. 374 Barnes PM and Schoenborn CA. Trends in Adults 356 McDonald NC. “Active Transportation to School: Receiving a Recommendation for Exercise or Trends among U.S. Schoolchildren, 1969-2001.” Amer- Other Physical Activity From a Physician or Other ican Journal of Preventive Medicine, 32(6): 509-16, 2007. Health Professional. NCHS Data Brief, 86, 2012. 357 .S. Centers for Disease Control and Prevention. U 375 Ibid. The Association between School-based Physical Ac- 376 Barnes PM and Schoenborn CA. Trends in Adults tivity, Including Physical Education, and Academic Receiving a Recommendation for Exercise or Performance. Atlanta, GA: U.S. Department of Other Physical Activity From a Physician or Other Health and Human Services, 2010. Health Professional. NCHS Data Brief, 86, 2012. 358 later SJ, Ewing R, Powell LM, et al. “The Associa- S 377 Ibid. tion Between Community Physical Activity Settings 378 Conroy DE, Elavsky S, Hyde AL, and Doerksen SE. and Youth Physical Activity, Obesity, and Body Mass The Dynamic Nature of Physical Activity Inten- Index.” The Journal of Adolescent Health (epub ahead tions: A Within-Person Perspective on Intention- of print), 2010. Behavior Coupling. Journal of Sport & Exercise 359 Ibid. Psychology, 33: 807-827, 2011. 360 ell JF, Wilson JS, and Liu GC. “Neighborhood B 379 Conroy DE, Elavsky S, Hyde AL, and Doerksen SE. Greenness and 2-Year Changes in Body Mass Index The Dynamic Nature of Physical Activity Inten- of Children and Youth.” American Journal of Preven- tions: A Within-Person Perspective on Intention- tive Medicine, 35(6): 547-553, 2008. Behavior Coupling. Journal of Sport & Exercise 361 owell L, Slater S, and Chaloupka F. “The Relation- P Psychology, 33: 807-827, 2011. ship between Community Physical Activity Settings 380 Penn State, (2012). Physical activity yields feel- and Race, Ethnicity and Socioeconomic Status.” Ev- ings of excitement, enthusiasm. [Press Release]. idence-Based Preventive Medicine, 1(2): 135-44, 2004. http://www.eurekalert.org/pub_releases/2012-02/ 362 icycling and Walking in the United States. Washing- B ps-pay020812.php (accessed April 12, 2012). ton, D.C.: Alliance for Biking & Walking, 2010. 381 Wells HF and Buzby JC. Dietary Assessment of Major http://www.peoplepoweredmovement.org/site/ Trends in U.S. Food Consumption, 1970-2005. Eco- index.php/site/benchmarkingdownload/ (ac- nomic Information Bulletin No. 33. Washington, cessed April 13, 2010). D.C.: Economic Research Service, U.S. Department 363 alking: A Step in the Right Direction. In National W of Agriculture, 2008. Institute of Diabetes and Digestive and Kidney Diseases. 382 .S. Department of Agriculture, Economic Re- U http://win.niddk.nih.gov/publications/PDFs/ search Service. “Loss-Adjusted Food Availability: WIN_Walking.pdf (accessed April 11, 2012). Spreadsheets -- Calories.” http://www.ers.usda.gov/ 364 assett DR, Wyatt HR, Thompson H, Peters JC and B Data/foodconsumption/spreadsheets/foodloss/ Hill JO.  Pedometer-Measured Physical Activity and Calories.xls#Totals!a1 (accessed March 5, 2010). Health Behaviors in U.S. Adults. Medicine and Sci- 383 Economic Research Service. “Loss-Adjusted Food ence in Sports and Exercise, 42(10): 1819-1825, 2010. Availability.” 384 Piernas C and Popkin BM. “Trends in Snacking among U.S. Children.” Health Affairs, 29(3): 398- 404, 2010. 122 385 National Heart, Lung and Blood Institute.  Larger 407 Lovasi GS, Hutson MA, Guerra M, Neckerman KM. Portion Sizes Contributing to U.S. Obesity Problem.  Built Environments and obesity in disadvantaged http://www.nhlbi.nih.gov/health/public/heart/ populations. Epidemiol Rev. 31: 7-20, 2009. obesity/wecan/news-events/matte1.htm  (accessed 408 Rundle A, Neckerman KM, Freeman L, et al. August 7, 2012).  Neighborhood food environment and walkability 386 American Heart Association.  Nutrition and Cardio- predict obesity in New York City. Environ Health vascular Diseases: Statistical Fact Sheet 2012 Update.  Perspect, 117(3): 442-447, 2008. http://www.heart.org/idc/groups/heart-public/@ 409 Morland K, Wing S, and Diez Roux A.  “The Con- wcm/@sop/@smd/documents/downloadable/ textual Effect of the Local Food Environment on ucm_319591.pdf  (accessed July 10, 2012).  Residents’ Diets: The Atherosclerosis Risk in Com- 387 Ibid. munities Study.” American Journal of Public Health, 388 Hellmich N.  Americans need to try harder 92(11): 1761-7, 2002. to eat fruits, vegetables.  USA Today July 9, 410 Moore L and Diez Roux A. “Associations of Neigh- 2012.    http://www.usatoday.com/news/health/ borhood Characteristics with the Location and story/2012-07-10/eating-fruits-and-vegetables- Type of Food Stores.” American Journal of Public healthy/56118742/1 (accessed August 7, 2012). Health, 96(2): 325-31, 2006. 389 Wells and Buzby, Dietary Assessment of Major Trends, 411 U.S. Department of Health and Human Services and p. 7-8 U.S. Department of Agriculture. Dietary Guidelines for 390 Economic Research Service. “Loss-Adjusted Food Americans, 2010. 7th Edition, Washington, D.C.: U.S. Availability.” Government Printing Office, December 2010. 391 Wang YC, Bleich SN, and Gortmaker SL. “Increas- 412 Finucan MM, Stevens GA, Cowan MJ, et al. Na- ing Caloric Contribution from Sugar-Sweetened tional, regional, and global trends in body-mass Beverages and 100 Percent Fruit Juices among U.S. index since 1980: systematic analysis of health Children and Adolescents, 1988-2004.” Pediatrics, examination surveys and epidemiological studies 121(6): 1604-14, 2008. with 960 country-years and 9·1 million participants. 392 abey SH, Jones M, Yu H and Goldstein H. Bubbling B Lancet, 377(9765): 557-567, 2011. Over: Soda Consumption and Its link to Obesity in Califor- 413 Ogden CL, Carroll MD, Kitt BK, Flegal KM. Preva- nia. UCLA Center for Health Policy Research, 2009. lence of Obesity in the United States, 2009-2010. 393 Bleich SN, Wang CY, Wang Y et al. Increasing NCHS Data Brief, 82: 1-8, 2012. consumption of sugar-sweetened beverages among 414 Ibid. US adults: 1988–1994 to 1999–2004. Am J Clin Nutr 415 Krauss RM and Eckel RH. The obesity problem. N 89,372–381, 2009. ENgl J Med, 338(16): 1156-1158, 1998. 394 Ibid. 416 Hartz AJ, Rupley DC, Kalkhoff RD, Rimm AA. 395 Bremer AA, Auinger P, and Byrd RS. “Relation- Relationship of obesity to diabetes: influence of ship between Insulin Resistance–Associated obesity level and body fat distribution. Prev Med, Metabolic Parameters and Anthropometric Mea- 12(2): 351-357, 1983. surements with Sugar-Sweetened Beverage Intake 417 Lementowski PW and Zelicof SB. Obesity and os- and Physical Activity Levels in U.S. Adolescents. teoarthritis. Am J Orthop, 37(3): 148-151, 2008. Findings from the 1999-2004 National Health and 418 Zilli T, Chagnon M, Van Nguyen T, et al. Influence Nutrition Examination Survey.” Archives and Pediat- of abdominal adiposity, waist circumference, and ric and Adolescent Medicine, 163(4): 328-35, 2009. body mass index on clinical and pathologic findings 396 Guthrie JF, Lin BH, and Frazao E. “Role of Food in patients treated with radiotherapy for localized Prepared Away from Home in the American Diet, prostate cancer. Cancer, 116(24): 5650-5658, 2010. 1977–78 versus 1994–96: Changes and Conse- 419 i Mhurchu, Bennett D, Lin R, et al. Obesity and N quences.” Journal of Nutrition Education and Behav- health-related quality of life: results from a weight ior, 34(3):140–50, 2002. loss trial. N Z Med J, 117(1207): U1211, 2004. 397 National Restaurant Association. 2012 Restaurant 420 teppan CM, Bailey ST, Bhat S, et al. The hor- S Industry Pocket Factbook. http://www.restaurant. mone resistin links obesity to diabetes. Nature, 409 org/pdfs/research/PocketFactbook_2012.pdf (ac- (6818): 307-312, 2001. cessed July 10, 2012). 421 uk SH, Sacco RL, Boden-Albala B, et al. Ab- S 398 Ibid. dominal obesity and risk of ischemic stroke: the 399 Guthrie JF, Lin BH, and Frazao E. “Role of Food Northern Manhattan Stroke Study. Stroke, 34(7): Prepared Away from Home in the American Diet, 1586-1592, 2003. 1977–78 versus 1994–96: Changes and Conse- 422 ang YC et al. Health and Economic Burden of W quences.” Journal of Nutrition Education and Behav- the Projected Obesity Trends in the USA and the ior, 34(3):140–50, 2002. UK. The Lancet, 378, 2011. 400 National Restaurant Association. 2012 Restaurant 423 edden R, Penfound J, Garrow JS. The Harrow S Industry Pocket Factbook. http://www.restaurant. Slimming Club: analysis of the results obtained in org/pdfs/research/PocketFactbook_2012.pdf (ac- 249 members of a self-financing, non-profit-making cessed July 10, 2012). group. J Hum Nutr, 35(2): 128-133, 1981. 401 enters for Disease Control and Prevention.  Second C 424 ole TJ, et al. Establishing a standard definition C National Report on Biochemical Indicators of Diet and Nu- for child overweight and obesity worldwide: inter- trition in the U.S. Population 2012.  Atlanta, GA: Na- national survey. BMJ. 320, 1240–1243, 2000. tional Center for Environmental Health, April 2012.   425 zzati M, Martin H, Skjold S. Trends in national E 402 Ibid. and state-level obesity in the USA after correction 403 Ibid. for self-report bias: analysis of health surveys. J R 404 Ibid. Soc Med, 99(5): 250-257, 2006. 405 Ibid. 406 Ibid. 123 1730 M Street, NW, Suite 900 Washington, DC 20036 (t) 202-223-9870 (f) 202-223-9871