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The Weight of the Nation

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Written in collaboration with Elena Hoffnagle

Last week, obesity took center stage in Washington, D.C. with the conference "The Weight of the Nation," sponsored by the Centers for Disease Control and Prevention (CDC) that convened researchers, advocates and clinicians to tackle the epidemic facing our country today. Tonight, HBO will air a documentary on this issue. While obesity rates have increased dramatically over the past 30 years and solutions to address the issue have been slow to show impact, we are at a critical turning point for combatting this major public health problem in our country today. Currently, we know more than ever about the most successful strategies to help Americans live healthier lives, reduce obesity rates, and decrease medical costs. Now it is time to take the actions needed to tip the scales on obesity using innovative "health in all policies" approaches.

In the U.S., two-thirds of adults and one-third of children are overweight or obese. For the first time in the history of our nation, there are more obese people than overweight ones, and it is estimated that unless we can reverse this alarming trend, by 2030 42 percent of the U.S. population will be obese. Obesity increases the risk for many chronic diseases including Type 2 diabetes, heart disease, stroke, some types of cancer, gout, and sleep apnea. Due to the rise in obesity rates and the resulting health-damaging effects, the current generation of American children may be the first not to live as long or be as healthy as their parents. For Latino and African-American children, the predictions are especially grim -- 50 percent of these youth are expected to develop Type 2 diabetes in their lifetime.

Obesity is not only a problem that undermines the nation's health, but it is also an economic and national security threat. These obesity-related diseases account for an estimated $190 billion in yearly medical expenditures, 21 percent of all medical spending in America today, and drive up the cost of medical care for everyone, even those not directly affected by the problem. Some experts believe that the health care costs of obesity have surpassed the health spending resulting from tobacco use. Currently, 27 percent of our nation's young adults, ages 18-24, are ineligible to enroll in the military because of their weight. There are also indirect costs of obesity, including the value of income lost from decreased productivity, restricted activity and absenteeism -- accounting for an estimated $450 billion annually.

Our health habits, the choices we make regarding food and exercise -- and the communities we live in, including our transportation systems, schools, workplaces, environments and U.S. agricultural policies -- all impact our health. "Health in all policies" solutions are urgently needed to address the complex causes of the obesity epidemic. The decades of experience that public health leaders and policymakers have gained while addressing this issue show that a focus solely on personal responsibility and individual behavior change does not go far enough. Now what is needed is a systems approach and the expanded involvement of new partners from all sectors of society, including government, business, advocacy, health care, food and beverage manufacturers, restaurants, grocery stores, and media. All stakeholders have a role in making healthier food more accessible and the easy choice, as well as creating a social movement for obesity prevention. Important steps forward in a multi-sector approach have been the White House's establishment of a Childhood Obesity Taskforce involving all agencies of government, and first lady Michelle Obama's leadership in creating the Let's Move campaign.

At the Weight of the Nation Conference, the Institute of Medicine (IOM) released a report, Accelerating Process in Obesity Prevention, which evaluated hundreds of proposed strategies for their promise to achieve this goal over the next decade. Five strategies were identified that collectively take a system's approach to strengthening the country's obesity prevention efforts.

  • Make physical activity an integral and routine part of life. This approach includes enhancing the built environment -- for example, improving sidewalks and bike paths, and adopting physical activity requirements for all schools and licensed child care providers. Since it takes running three miles to burn off the calories consumed in a single candy bar, physical activity is just one piece of the puzzle and solution.
  • Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice. Healthier foods should be available at all locations and in all environments. Policies to reduce access to sugar-sweetened beverages, increase availability of drinking water, and use incentives to attract supermarkets and grocery stores to underserved neighborhoods have all been successful approaches.
  • Transform messages about physical activity and nutrition. The average child sees as many as 7,600 ads for food products a year, and over 40 percent of those ads are for candy, snacks and fast food. The marketing of unhealthy products to children must be regulated, limited, and replaced with effective social marketing campaigns for physical activity and healthy foods, as well as easy-to-read nutrition labeling on the front of packages and on restaurant menus.
  • Expand the roles of health care providers, insurers and employers in obesity prevention. Doctors and health care providers should conduct obesity screenings, and provide preventive services. Workplaces, where adults spend 25 percent of their time, should increase opportunities for physical fitness at the worksite and offer breastfeeding-friendly environments for new mothers as well.
  • Make schools a national focal point of obesity prevention Children spend up to half of their waking hours and consume between one-third and one-half of their daily calories at school, making this environment a key location for obesity prevention. Schools can play a significant role by requiring physical activity, improving nutrition standards for school meals and a la carte items, and providing a nutrition education curriculum.

By addressing the obesity epidemic with a systems approach that involves all sectors of society, the focus will be shifted toward improving environments where people spend time -- their homes, streets, schools, and workplaces. Individuals need environments that support and encourage healthy choices, where healthy food is accessible and affordable and there are safe and easy opportunities for physical activity. People must also be educated, empowered, and incentivized to make the right choices. Take for example a full-service grocery store in a low-income neighborhood. This new store won't improve health and lower obesity rates if individuals buy the same soda, candy, and chips that were previously purchased at a small corner store. Real progress in tipping the scales on obesity will require transformations in the way we interact with food and our physical activity habits. We can no longer afford to not change our current way of life.

However, while the recommendations of the IOM report are critical, there was minimal attention to "out of the box" thinking. Many of the recommendations have already been proposed in previous reports over a decade ago, including The Healthier U.S. Initiative in 2002 and the Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity in 2001. Furthermore, there was a lack of emphasis at both the Weight of the Nation Conference and in the Institute of Medicine report on the important role that new technology and social media can play in addressing this epidemic by empowering individuals and providing them with personalized tools for behavior change. Despite the proliferation and transformational effects of information technology in business, entertainment, shopping and politics, these tools have still not yet been fully harnessed for obesity prevention. New partnerships with IT companies are needed to create public health technology as 21st-century tools for obesity prevention. Another important area that was not emphasized at the conference is the macroeconomic forces fueling the obesity epidemic -- trade policies, agricultural subsidies for corn and soy, support for large agribusinesses at the expense of smaller, local fruit and vegetable producers, lobbying by the food industry, and the food industry's support of many anti-hunger and anti-obesity initiatives. There was also little mention of the potential to use federal food assistance programs, such as the Supplemental Nutrition Assistance Program (formerly the Food Stamp Program) as a public health tool to improve the health of 1 out of 7 Americans, 50 percent of whom are children.

Policy recommendations must have evaluation as a key component. More research is needed to create the evidence base for best practices. (Visit www.snaptohealth.org to contribute your perspectives and ideas.) The NIH, CDC, and the Robert Wood Johnson Foundation have increased their investments in obesity prevention and have provided leadership on this issue. Collaboration with non-traditional partners will be necessary. Special attention must be turned to the communities most at risk -- obesity disproportionately affects minority, low-income and rural populations. In low-income communities, hunger, food insecurity and obesity often coexist to create additional burdens. This combination of pressures makes it difficult for some families to manage scarce resources, achieve a nutritious diet and maintain a healthy weight.

We now must act boldly to combat the obesity epidemic. There are many opportunities across the lifespan, but it will require a shift in social norms and an unprecedented social movement for obesity prevention. Broad implementation of successful strategies and innovation are urgently needed to create a healthier and more prosperous future for people in the United States. As an ancient proverb underscores, "He [let's also make that she] who has health has hope, and she who has health has everything."

Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of the Huffington Post. She is also the Director of the Health and Medicine Program at the Center for the Study of the Presidency and Congress in Washington, D.C., a Clinical Professor at Georgetown and Tufts University Schools of Medicine, and Chair of the Global Health Program at the Meridian International Center.

Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, as Chief of the Behavioral Medicine and Basic Prevention Research Branch and as Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the US Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal is the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association and was named a Rock Star of Science by the Geoffrey Beene Foundation. To learn more about Susan Blumenthal, M.D., visit 4globalhealth.org

Elena Hoffnagle, a recent graduate of Yale University, is a Health Policy Research Associate at the Center for the Study of Presidency and Congress in Washington D.C.

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