Preventing
Childhood Obesity:
Health in the Balance
Ross C. Brownson, Ph.D.
St. Louis University
School of Public Health
APHA Conference
Washington, DC
Background
• Congressional request (2002)
• Sponsors: CDC, NIH, ODPHP, RWJF
• 19-member multidisciplinary committee
• Task: prevention-focused action plan
• 24 months
Committee on Prevention of Obesity
in Children and Youth
JEFFREY P. KOPLAN (Chair), Emory SHIRIKI K. KUMANYIKA, University of
University Pennsylvania
DENNIS M. BIER, Baylor College of BARBARA J. MOORE, Shape Up
Medicine America!
LEANN L. BIRCH, Pennsylvania State ARIE L. NETTLES, University of
University Michigan
ROSS C. BROWNSON, St. Louis RUSSELL R. PATE, University of South
University Carolina
JOHN CAWLEY, Cornell University JOHN C. PETERS, Procter & Gamble
GEORGE R. FLORES, The California Company
Endowment THOMAS N. ROBINSON, Stanford
SIMONE A. FRENCH, University of University
Minnesota CHARLES ROYER, University of
SUSAN L. HANDY, University of Washington
California, Davis SHIRLEY R. WATKINS, SR Watkins &
ROBERT C. HORNIK, University of Associates
Pennsylvania ROBERT C. WHITAKER, Mathematica
DOUGLAS B. KAMEROW, RTI Policy Research
International
An Epidemic of Childhood Obesity
• Since the 1970s, obesity prevalence has
• Doubled for preschool children aged 2-5 years
• Doubled for adolescents aged 12-19 years
• Tripled for children aged 6-11 years
• More than 9 million children and youth over 6
years are obese
• Reflect similar trends
• U.S. adults
• Adults and children internationally
Terminology
• Obesity refers to children and youth who have a
body mass index (BMI) equal to or greater than
the 95th percentile of the age- and gender-specific
BMI charts of the Centers for Disease Control and
Prevention (CDC)
• In most children, BMI values > 95th percentile are
known to indicate elevated body fat and to reflect
the presence or risk of related diseases
No BMI-for-age references for children < 2 years
Trends in Childhood Obesity Prevalence
Prevalence
1963-67 1971-74 1976-80
(%)
20 1988-94 1999-2000
15
10
0
Boys 6-11 y Girls 6-11 y Boys 12-19 y Girls 12-19 y
SOURCE: Ogden et al.. J Am Med Assoc. 2002; 288(14):1728-1732.
Implications for Children and Society
Physical, social, emotional health consequences
Physical Health Emotional Health
Glucose intolerance and insulin Low self-esteem
resistance Negative body image
Type 2 diabetes Depression
Hypertension
Dyslipidemia Social Health
Hepatic steatosis Stigma
Cholelithiasis Negative stereotyping
Sleep apnea Discrimination
Orthopedic problems Teasing and bullying
Social marginalization
Framework for Understanding Obesity
in Children and Youth
Social Norms and Values
Primary and Secondary Leverage Points
● Food and Agriculture ● Education ● Media
● Government ● Public Health ● Health Care
● Land Use and Transportation
● Leisure ● Recreation
Behavioral Settings
● Home ● School ● Community
Genetic, Psychosocial, and
Other Personal Factors
Food and
Physical
Beverage
Activity
Intake
Energy
Expenditure
Energy Intake
Energy
Imbalance
Obese Children &
Youth
Energy Balance
Energy intake = Energy
expenditure
For children, maintain
energy balance at a
healthy weight while
protecting health, growth
and development, and
nutritional status
Review of the Evidence
• The committee strongly endorsed an action plan
based on the best available evidence instead of
waiting for the best possible evidence
• Integrated approach to the available evidence
• Limited obesity prevention literature upon which to
base recommendations
• Parallel evidence from other public health issues
• Dietary and physical activity literature
Key Conclusions
• Serious nationwide health problem requiring a
population-based prevention approach
• Goal is to create supportive environments that
promote energy balance – healthful eating behaviors
and regular physical activity
• Societal changes needed at all levels involving
multiple sectors and stakeholders
What is Needed?
• Leadership
• Evaluation
• Resources
• Efforts at all levels
• Change in societal norms
Obesity Prevalence Healthful Eating
Increasing Behaviors and
Physical Activity
are the Norm
Changing Social Norms
Public Health Precedents
• Tobacco control
• Underage drinking
• Highway safety
• Use of seatbelts and child car seats
• Vaccines
• Fluoridation
Key Stakeholders to Involve
• Children, youth, parents, families
• Child- and youth centered organizations; community-based organizations
• Community development and planning
• Employers and work sites
• Food and beverage industries, food producers, advertisers, marketers, and
retailers
• Foundations and nonprofit organizations
• Government agencies and programs
• Health-care providers and delivery systems; professional societies
• Health-care insurers, health plans, and accrediting organizations
• Mass media, entertainment, recreation, and leisure Industries
• Public health professionals
• Recreation and sports enterprises
• Researchers
• Schools, child care programs
Action Plan for Obesity Prevention
• National Public Health Priority
• Healthy Marketplace and Media
Environments
• Healthy Communities
• Healthy School Environment
• Healthy Home Environment
National Priority
Government at all levels to provide coordinated leadership
• Federal coordination
• Program and research efforts to prevent
childhood obesity in high-risk populations
• Resources for state and local grant programs,
support for public health agencies
• Independent assessment of federal nutrition
assistance programs and agricultural policies
• Research and surveillance efforts
Healthy Marketplace and Media
• Healthful products, expand meals, create physical
activity opportunities
• Labeling
• New advertising and marketing guidelines
• Multi-media and public relations campaign
Healthy Communities
• Mobilize communities
• Build diverse coalitions
• Develop and evaluate community programs
• Address barriers for high-risk populations
• Enhance built environment
• Revise city planning practices
• Improve opportunities for physical activity
• Prioritize capital improvement projects
• Improve access to healthful food
Examples of Community Programs
• Kids Off the Couch – Modesto, CA
• Provides information and tools to parents and caregivers
• Feet First – Seattle, WA
• Neighborhood assessments of potential for physical activity-
walking, bike paths
• Edible Schoolyard – Berkeley, CA
• 6-8 graders participate in school garden seed-to-table
approach (ecoliteracy)
• Safe Routes to Schools
• Education, engineering, and encouragement approaches to
walk- and bike-to-school programs
Healthy Schools
• Develop nutritional standards for all school foods
• Increase physical activity to at least 30 minutes/day
• Enhance curriculum
• Reduce in-school advertising
• Utilize school health services
• Provide individual student BMI assessments to parents
• Bolster after-school programs
• Use schools as community centers
Healthy Homes
• Exclusive breastfeeding first 4-6 months
• Provide healthful foods - consider nutrient
quality and energy density
• Encourage healthful decisions re: portion size,
how often and what to eat
• Encourage and support regular physical activity
• Limit recreational screen time to < 2 hours/day
• Parents should be role models
• Discuss child’s weight with health care provider
School Food
Develop nutritional standards for all school foods
• Currently
– Minimal federal regulations beyond school meal programs;
many states and localities have adopted stricter standards
• Proposed
– All foods sold and served in schools meet nutritional standards –
includes contents of vending machines, school stores, fundraisers
– State education agencies and local school boards should adopt
and implement these standards or develop stricter standards for
their local schools
Physical Activity
Current recommendations – 60 minutes of
moderate to vigorous physical activity each day
– At least 30 minutes at school
• Currently
– Reduced PE classes, reduced participation in PE particularly in
high school students
• Proposed
– Expand intramural and extramural options
– Innovative, varied, and engaging activities
– Promote walking and biking to school
Walking and Biking to School
• 1969 – 48% of all students walked or biked, among those
within a mile 90% walked or biked
• 1999 – 19% walked and 6 % biked at least once a week
• Current barriers
– Schools sited at distances from neighborhoods
– Parental concerns about safety, time, weather
– Lack of sidewalks, safe street crossings
• Recommendations
– Promote walking/biking to school programs
– Evaluate interventions
School Environment
• Promote consistent school environment with healthy
choices
• Other areas to address
– Increase and enhance wellness curriculum
– Reduce advertising in schools
– Engage school health services
– Annually assess student BMI and provide information to
parents
– Enhance after-school programs
– Use schools as community centers
– Evaluate school programs and policies
Summary
• Epidemic of childhood obesity is upon us
• Many sectors need to be mobilized to make positive
changes
– Comprehensive approaches are key
• Several aspects of the built environment are likely to
be key
– School & community
• Should rely in existing evidence-based strategies and
new, innovative approaches should be evaluated
• It will take years to decades to reverse this trend
Preventing
Childhood Obesity:
Health in the Balance
To order:
www.nap.edu
Executive summary available
for free download
For more information:
www.iom.edu/obesity
