# Presentation: 465014

##  Overweight and ObesityEducational Efforts of the NHLBI Obesity Education Initiative 

** ****Overweight and Obesity****Educational Efforts of the ****NHLBI Obesity Education Initiative**

**Karen Donato, S.M., R.D.****Coordinator, NHLBI Obesity Education Initiative**

## Alarming Trends in Health of the U.S.

**Alarming Trends in Health of the U.S.**

**Notes:**
“Overweight and obesity have certainly been in the news.  It is affecting everyone and is linked to serious health problems.
One newsworthy item that has received some attention is that overweight and obesity may soon cause as much preventable death and disease as cigarette smoking” (300,000 for obesity and 400,000 for smoking).  

## Prevalence of Overweight In Adults and Children 

*JAMA*, October 9,2002; vol 288, no.14

**Notes:**
We have all heard the proclamations that obesity is at epidemic numbers.  You can see here the latest prevalence information from NHANES 1999-2000 published in the October issue of JAMA.  
Overweight and obesity now affects 65% of adults or 122 million people.  
Obesity which is a BMI of > 30 has increased to 31% of adults up from 23% in NHANES III. More women (33%) than men (23%) are obese and the problem is greatest among African American Women (50%) compared to Mex American (40%) and white women (30%).
And the problem has also increased in children and adolescents with the prevalence of overweight in children doubling in 25 years to 15% and tripling in adolescents to also 15% 
(nine million children).

## Percent overweight (25-29.9) and obese ( 30 BMI) in Latin American women, 15-49 years

**%**

-   Bol     Brazil     Col        DR      Guat  Haiti Hond   Mex     Nic       Peru     USA

**’****88-’94**

**Source: Martorell, et al, European Journal of Clinical Nutrition, 2000**

##  Obesity Trends* among U.S. AdultsBRFSS 1988

**Notes:**
As, a nation, we are getting heavier. Many of us here are familiar with maps that show us the trends in obesity prevalence by state.  
Obesity is defined as a BMI of > 30, or approximately 30 pounds overweight. 
The light blue states are those where obesity affects less than 10% of adults, 
the rates increase to 10 to 15% of adults in the royal blue states, while in the navy blue states the rates are the highest at greater than 15% of adults. 

## Obesity Trends* Among U.S. AdultsBRFSS, 1991

**Obesity Trends* Among U.S. Adults****BRFSS, 1991**

**(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)**

## Obesity Trends* Among U.S. AdultsBRFSS, 1996

**Obesity Trends* Among U.S. Adults****BRFSS, 1996**

- Source: Mokdad A H, et al.* J Am Med Assoc* 1999;282:16,2001; 286:10.

**(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)**

**Notes:**
By 1996, VA had moved in with the 29 other states where 15-19% of adults were considered obese

## Obesity Trends* Among U.S. AdultsBRFSS, 1999

**Obesity Trends* Among U.S. Adults****BRFSS, 1999**

**(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)**

## Obesity Trends* Among U.S. AdultsBRFSS, 2002

**(*BMI ********30, or ~ 30 lbs overweight for 5’4” person)**

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

**(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)**

**Obesity Trends* Among U.S. Adults****BRFSS, 2002**

## Obesity Trends* Among U.S. AdultsBRFSS, 1991-2002

**2002**

**Obesity Trends* Among U.S. Adults****BRFSS, 1991-2002**

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

**(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)**

**Notes:**
In 1991, most of the states had fewer than 15 to 19% of adults considered obese.  
In 2002, we have no states with less than 15-19% of adults obese
Most states have 20-24% of adults obese, with 3 having more than 25% of adults obese.
These are frightening trends that warrant our attention.

## NHLBI Obesity Education Initiative 

- Two pronged strategy:
- High-risk strategy: targets individuals experiencing or at high risk for adverse health effects and medical complications with overweight/obesity
- Population-based strategy: focuses on the prevention of overweight/obesity and physical inactivity

**Notes:**
To illustrate how programs are implemented, again I will use the Obesity Education Initiative.  As I stated earlier, we considered the public health significance of the problem, the consensus of the science, and recommendations from advisory panels.
One such group advised NHLBI in 1991 that the OEI program should be established and have a two pronged strategy:
The high risk strategy targets individuals experiencing or at high risk for adverse health effects and medical complications because they are overweight or obese. 
The population strategy tackles the problem from the standpoint of prevention of overweight and physical inactivity. This strategy involves the development of messages and programs encouraging all people to increase physical activity and improve nutritional habits in order to help avoid overweight and obesity. 
I will illustrate both strategies.

## The Clinical Guidelines

**Notes:**
In 1998, NHLBI in collaboration with NIDDK released The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report.  These guidelines were the first evidence based guideline issued by the Federal govt. dealing with this issue.  

## Assessment of Overweight and Obesity

- Body Mass Index  (BMI):
-           _weight (lbs) X 703_
- 		        height (inches2)
-  Overweight = 25 - 29.9 kg/m2
-  Obesity = _>_ 30 kg/m2
-  Waist Circumference
- High risk:
- Men >102 cm (40 in)
- Women >88 cm (35 in)
- Other risk factors

**Notes:**
The guidelines recommended three measures  important when assess overweight and obesity in adults 
 BMI is the measure of choice as a practical indicator of the severity of obesity. Overweight is defined as a BMI of 25-29.9, and obesity is defined as BMI > 30.
A  BMI of 30 is approximately someone who is 5’7” tall  and weighs 190 pounds; 
a BMI of 25 would be 160 pounds.
Limitations of BMI as a measure of total body fat overestimating total body fat in persons who are very muscular and underestimating body fat in persons who have lost muscle mass (e.g., the elderly).
Waist circumference, another independent predictor of risk factors and morbidity, should also be measured.  A high waist circumference is associated with an increased risk for type 2 diabetes, dyslipidemia, hypertension, and CVD in patients with a BMI in a range between 25 and 34.9 kg/m2.  
High risk in men is defined as > 102 cm ( > 40 in) and in  women, it is  > 88 cm ( > 35 in).
In addition, since people with other risk factors such as high blood cholesterol, high blood pressure, diabetes, smoking, etc. were considered at higher absolute risk, consideration of these risk factors were also thought to be important.

## Obesity-associated Morbidities

- Type 2 diabetes
- Heart disease
- Hypertension
- Stroke
- Cancer
- Sleep apnea

- Asthma
- Urinary incontinence
- Gallbladder disease
- Nonalcoholic FLD
- Osteoarthritis
- Psychological disorders

## NHANES III Age-Adjusted Prevalence of Hypertension* According to BMI

- *Defined as mean systolic blood pressure140 mm Hg, as mean diastolic  _>_90 mm Hg, or currently taking antihypertensive medication.

- Brown C, et al.  Body Mass Index and the Prevalence of
- Risk Factors for Cardiovascular Disease. *Ob Res.* 2000.

**Percent**

**Notes:**
Data from NHANES III show that the age-adjusted prevalence of high blood pressure increases progressively with higher levels of BMI in men and women.
The prevalence of high blood pressure in adults with BMI > 30 is 41.9 percent for men and 37.8 	percent for women, respectively, compared with 14.9 percent for men and 15.2 percent for women with BMI  25 (a relative risk of 2.1 and 1.9 for men and women, respectively).   

## Therapeutic Approaches

- Behavioral
- dietary changes
- increase activity
- decrease inactivity
- Pharmacologic
- Surgical

## Weight Loss Diet

- Individually planned caloric deficit diet
- Generally 500-1000 Kcal/day deficit
- <30% calories from fat
- <10% saturated fat
- Must reduce calories—not just fat—to promote weight loss.

**Notes:**
To succeed with weight loss, diets need to be planned with the individual in mind.   They need to take into account what the patient is currently consuming.  
A deficit of 500 to 1,000 kcal/day will produce a weight loss of 1 to 2 lb/week.
For weight loss,  a diet of 1,000 to 1,200 kcal for women and 1,200 to 1,500 kcal for men is recommended.
The LCD recommended in this report also contains nutrient compositions that will decrease other risk factors, notably, high serum cholesterol and hypertension
Also, reducing fat alone without reducing calories will not help patients lose weight.

## Physical Activity

- Modestly contributes to weight loss.
- May decrease abdominal fat.
- Increases cardiorespiratory fitness.
- Improves sense of well being and self efficacy.

**Notes:**
Physical activity should be recommended as part of a comprehensive weight loss and maintenance program. 
There is strong evidence that increased physical activity alone can create a caloric deficit and can modestly contribute to weight loss.  Efforts to achieve weight loss through physical activity alone generally produce an average of a 2 to 3 percent decrease in body weight or BMI.  
Physical activity may decrease abdominal fat.
There is strong evidence that increased physical activity increases cardiorespiratory fitness, with or without weight loss.  Improved cardiovascular fitness also improves the quality of life in overweight patients by improving mood, self-esteem, and physical function in daily activities.

## Physical Activity

- Most important in preventing weight regain
- Start slowly and increase gradually
- Can be single session or intermittent
- Start with walking 30 minutes 3 days/week
- Increase to 45 minutes 5 or more days/week
- Encourage increased “lifestyle” activities –don’t have to join a gym
- Get pedometer –increase steps by 2,000/day

**Notes:**
Physical activity is most important in helping to prevent weigh regain.  
In addition, sustained physical activity has the benefit of reducing overall CHD risk beyond that produced by weight reduction alone.  
For most obese patients, physical activity should be initiated slowly, and the intensity should be increased gradually.  Initial activities may be walking or swimming at a slow pace.  With time, depending on progress, the amount of weight lost, and functional capacity, the patient may engage in more strenuous activities. 
A regimen of daily walking is attractive; patients can start by walking 30 minutes, 3 days a week, and can build to 30 to 45 minutes of more intense walking at least 5 days a week and preferably most, if not all, days.  With this regimen, an additional 100 to 200 calories per day of physical activity can be expended.  Caloric expenditure will vary depending on the individual’s body weight and intensity of the activity.
 People can select activities that they enjoy and that fit into their daily lives.  Getting a pedometer and encouraging 10,000 steps a day.  

## Goals of Weight Management/Treatment

- Prevent further weight gain
- Reduce body weight
- Initial goal:   body weight by 10 percent
- If goal achieved, further weight loss can be attempted
- Reasonable timeline:  6 months of therapy
- Moderate caloric deficits
- Weight loss 1 to 2 lbs/week
- Maintain a lower body weight over long term

**Notes:**
The general goals of weight loss and management are: 
 (1) at a minimum, to prevent further weight gain.   Most adults gain on average 1.8 to 2 pounds a year.   We can prevent this increase by reducing calories by 100 kcal per day.  This can easily be accomplished by a few  less bites of food, walking one mile, or increasing steps by 2000 per day.
2 ) to reduce body weight -- The rationale for this initial goal is that even moderate weight loss, i.e., 10 percent of initial body weight, can decrease the severity of obesity-associated risk factors;  It can set the stage for further weight loss, if indicated; and it is realistic and can be achieved and maintained over time.  
and 
(3) to maintain a lower body weight over the long term.  
For overweight patients with BMIs in the typical range of 27 to 35, a decrease of 300 to 500 kcal/day will result in weight losses of about 1⁄2 to 1 lb/week and a 10 percent weight loss in 6 months.  For more severely obese patients with BMIs   35, deficits of up to 500 to 1,000 kcal/day will lead to weight losses of about 1 to 2 lb/week and a 10 percent weight loss in 6 months.

## Professional Education Materials

**Notes:**
One such product was the an abbreviated version of the guideline in the form of The Practical Guide.  This was developed In partnership with the North American Association for the Study of Obesity.  And, the American Academy of Family Physicians provided 100,000 copies to its members.
Other tools developed to disseminate the messages include a primary care provider kit and the Aim for a Healthy Weight Website.  The site provides practical information on nutrition and physical activity for health professionals and the public. 

## Palm OS Devices                                

**Notes:**
The latest technology offers new opportunities to have information in the palm of our hand through the use of Palm OS applications. 
One of the first applications we tried was the BMI calculator and it was received with overwhelming success. 76,000 copies  have been disseminated 
Our latest interactive Palm OS application is information from the full guideline and practical guide which allows the provider to enter patient information and then be directed to weight loss goals and treatment options. 
Overall 120,000 copies of both programs have been distributed.

## Slides and CME Modules

**http://www.nhlbi.nih.gov/obesitycme/**

**Notes:**
The slide show is also a very popular site and contains 150 slides separated into 6 different sections complete with notes.
As of March 2003, we completed two online CME modules in cooperation with NAASO; One deals with assessment and the other deals with treatment of the overweight. It offers free 2 hours of category I CME credits for each module.  
Approximately 2000 people have registered for the course with over 900 getting CME credit.

## Public Education Materials

**Notes:**
The kit also contains patient education materials as tear sheets for providers to use with their patients.
Your Weight and Health Profile sheet allows providers to note BMI, waist circumference, other risk factors and discuss a patient’s overall risk. The patient is asked if they are ready to lose weight and if so what are their weight loss goals.
The other sheet includes Tips for Weight Loss Success that covers Being a Smart Planner, Keeping An Eye on the Size, questioning the amount of physical activity, and the need to balance your Food Checkbook
780 copies of the kit have been distributed 18.00/kit

## Portion Distortion:

**Portion Distortion:**
**Do You Know How Food Portions Have **
**Changed in 20 Years?**

**Notes:**
One recent addition to the Aim Website is Portion Distortion, to educate consumers on how portion sizes in the U.S. have increased over the years.  And have probably had some impact on the increasing rates of obesity.  As you will see, it is an interactive quiz.  Take out a pencil and paper and take the quiz to see how  well you all do.  

A study by Dr. Paul Rozen, of the University of PA, revealed that portions in Philadelphia restaurants were on average 25% larger than those served in Paris.  He recommends that public health experts pay more attention to the “ecology of eating”...we are not built to resist the highly palatable food available to us.

## French Fries 

**20 Years Ago**

**Today**

**210 Calories**
**2.4 ounces**

**How many calories are **
**in these fries?**

**610 calories**
**6.9 ounces**

**Calorie Difference: 400 calories**

** *****Based on 160 pound person**

- How  long will you have to
-  walk to burn* 400 calories?

- How to burn* 400 calories:
- _Walk leisurely for 1 hr 10 Minutes_

## Soda

**20 Years Ago**

**Today**

** ****85 Calories**
** ****6 1⁄2 ounces**

**Calorie Difference: 165 calories**

**How many calories are in this soda?**

** ****250 calories**
** ****20 ounces**

** *****Based on 160 pound person**

**How**** ****long would you have**
**to garden to burn 165 calories?**.

- How to burn* 165 calories:
- _Garden for 35 Minutes_

## Turkey Sandwich

**20 Years Ago**

**Today**

** ****320 calories **

**Calorie Difference: 500 calories**

**How many calories are in **
**this turkey sandwich?**

** ****820 calories**

** *****Based on 130 pound person**

- How long would you have to bike
- to burn up 500 calories?

- How to burn 500 calories:
- _Bike for 1 hour and 25 minutes_

## The Obesity Environment

**Consumption of energy encouraged!**
**Wide variety, low cost, good taste, high fat/energy dense foods available everywhere **
**Large portions**
**Expenditure of energy discouraged!**
**Reduction of jobs requiring physical labor**
**Reduction of PE at schools**
**Increased time spent watching TV, web, video games**
**Urban sprawl**

**Notes:**
When you look at the environment and energy intake.....Consumption of excess energy is  encouraged!
Wide variety, low cost, good taste, high fat/energy dense foods available everywhere 
Large portions

On the energy output side of the scale....Expenditure of energy discouraged!
Reduction of jobs requiring physical labor
Reduction of PE at schools
Increased time spent watching TV, web, video games
Urban sprawl...no sidewalks, long commutes, no neighborhoods with places to walk to.  

## Courtesy of Dr. Kelly Brownell

**Notes:**
The option of extra value meals is in most fast food outlets.  These options are great money makers for the fast food establishments costing them pennies, while offering consumers more calories than can be expended. 

## 8 oz

**8 oz**

**12 oz**

**16 oz**

**20 oz**

**34 oz**

- Courtesy of Dr. Kelly Brownell

**Notes:**
The driving force of “portion size” in the environment is one that requires our attention.  
Here you can see how  the size of a coke has increased 4 times over the years.  A coke that used to be 8 oz is now available to us in 34 oz.  Not only are we given more coke than we would ever need or ever want, but also more calories than we typically burn up.  
Show Hershey bar!!
And as you will see from the latest research on portion size, when people are given the choice, they are likely to drink all of this coke.

## Courtesy of Dr. Kelly Brownell

**Notes:**
So, what do you think happens when Mom brings home this container of cheese balls.....everyone eats far too many cheese balls than if mom brings home a smaller container.   And, this is just a typical snack before or after the main meal.

## But the obesity epidemic is 

**NOT** just an individual problem...

## WHOLE 

- WHOLE
- POPULATION

**Notes:**
The solution needs to address the entire population.  
No single factor in the environment has probably caused the epidemic of obesity, and unfortunately there is no silver bullet that will resolve it. 
Success in dealing with this epidemic depends not only on individual behavioral change, but also on group influences, institutional and community influences, and public policy. 
The resolution lies in the action of many people in many fields of endeavor.  It will require the work of urban planners, school officials, public health and medical professionals, policy makers and civic authorities.

## Population Strategy

- Parks and recreation:
- Provide a unique venue for children, adults, and seniors to learn about heart healthy lifestyles.
- Adopt programs to meet the needs of the community.
- Mobilize community partners and bring people together

**Notes:**
In addition to the high risk strategy, we also have attempts underway to prevent obesity by encouraging healthy eating and increased physical activity through our Hearts n”Parks program.  The effort has been done in collaboration with the National Recreation and Park Association and the American Dietetic Association.
When we began HnPs, we needed a venue into the community. Parks and recreation agencies needed to extend their brand as a source of  health information in their communities.  
They had the facilities, we had the know how.-- a formula for a successful partnership.

## Magnet Center Sites

**NV**

**NC**

**SC**

**GA**

**MI**

**OH**

**IN**

**IL**

**MO**

**FL**

**AZ**

**NM**

**MD**

**HI**

- Responsibilities Include:
-  A three year commitment to the Hearts N’ Parks program.
-  Expand heart-healthy programming efforts each consecutive year.
-  Utilize an extranet to communicate to other sites.
-  Administer the pre and post-test measures to personnel and            participants.
-  Evaluate the program’s sustainability and growth annually.
-  Report progress annually.
-  Serve as ambassadors for other sites.

**Notes:**
We have Hearts N’Parks efforts underway in    
50 Magnet Center sites located in 10 states 
We choose areas where the risk for CVD is high and the capability of the park and recreation departments is strong.
As a Magnet Center, the communities have made a 3 year commitment to implementing heart healthy programs and agreed to carry out the responsibilities shown here.

## Media Activities

**Notes:**
Mass media is a critical component to any national educational effort.
For Hearts N’Parks, each site works very hard to get visibility locally in their communities.  
And, we at NHLBI work to raise public visibility at the national level. 
As a result of this outreach, the media almost always call us for an interview or a comment when preparing a story on the community’s response to overweight and obesity. 
We regularly get calls from Reuters, Newhouse News, CNN and web-based media.  In fact, if you search Hearts N’Parks on Google, you will get over 90 hits.  We also receive many telephone calls from communities interested in joining us in Hearts N’Parks

## National Heart, Lung, and Blood Institute

**National Heart, Lung, and Blood Institute**

**Notes:**
Due to the interest and success of Hearts N’Parks, we have begun efforts to expand our activities at the community level through our Healthy Weight Community Outreach Initiative.  

## Healthy Weight Community Outreach Initiative

- Objectives
- Engage communities to take an active role in creating healthier environments that promote a healthy weight.
- Engage the public in recognizing individual and environmental factors that influence attempts to achieve and maintain a healthy weight
- Motivate health professionals to provide patients with clear messages about prevention of weight gain without the stigma that overweight and obese patients often feel.

**Notes:**
Our specific objectives are to:
Engage communities to take an active role in creating healthier hometown environments that promote a healthy weight, and give them the resources to do it. 
Engage the public in recognizing both individual and environmental factors that influence their attempts to achieve and maintain a healthy weight
Motivate health professionals to provide their patients with clear messages about prevention of inappropriate weight gain without the stigma that overweight and obese patients often feel.

## Healthy Weight Community Outreach Initiative

**Program Elements**
- National Media and Messaging
- Community Outreach
- Partnership Development
**Audiences**
- Primary:
- Youth
-  Parents (primary custodians)
- Secondary:
- Influencers (physicians, peers, teachers, coaches, others)

**Notes:**
The Healthy Weight Initiative will embrace the following program elements, which are very similar to those used in other National Education Programs.  
National Media and Messaging:  To motivate the public to take individual and community action to maintain a healthy weight, We will develop an umbrella theme and  materials such as television, radio and print advertising, brochures, videos and a Web site.
Community Outreach:  We will engage communities to take an active role in creating healthier environments that promote a healthy weight. 
Partnership Development:  We will strategically engage national, regional, and local organizations (including health professional associations) that have an infrastructure to reach target populations.   
The primary audiences will be children and their parents or care providers.
 The secondary audiences will be key influencers such as physicians, teachers, coaches and peers. 
As with all programs we will also develop a program evaluation component  that will provide information on our reach and exposure, as well as some indication of performance related to knowledge, attitudes and behavioral intent.

## OEI Web Page... www.nhlbi.nih.gov

**Notes:**
NHLBI’s materials plus more information for patients and the public can be found on the OEI’s Web page, “Aim for a Healthy Weight”, shown here.  
It is segmented by information for health professionals and information for patients and the public.