Strategy Development Workshop for Public Education on Weight
and Obesity


September 24-25, 1992


Summary Report


Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Bethesda, Maryland



WORKSHOP PARTICIPANTS


Speakers And Facilitators


Diane Bild, M.D., M.P.H.
Medical Officer
Division of Epidemiology andClinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 301
7550 Wisconsin Avenue
Bethesda, MD  20892

Patricia J. Elmer, Ph.D., R.D.
Assistant Professor
Division of Epidemiology
School of Public Health
University of Minnesota
1300 South Second Street, Suite 300
Minneapolis, MN  55454-1015

Leonard H. Epstein, Ph.D.
Professor of Psychiatry, Psychology, and Epidemiology
Western Psychiatric Institute
University of Pittsburgh
3811 O'Hara Street
Pittsburgh, PA  15213-2593

Robert W. Jeffery, Ph.D.
Professor
Division of Epidemiology
School of Public Health
University of Minnesota
1300 South Second Street, Suite 300
Minneapolis, MN  55454-1015

Arthur S. Leon, M.D.
Taylor Professor of Exercise Science and Health Enhancement
School of Kinesiology
University of Minnesota
110 Cooke Hall
Minneapolis, MN  55455

JoAnn E. Manson, M.D., Dr.P.H.
Associate Physician
Assistant Professor of Medicine
Harvard Medical School
900 Commonwealth East
Boston, MA  02215

John C. McGrath
Chief
Communications and Marketing Section
Communications and Public Information Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A21
9000 Rockville Pike
Bethesda, MD  20892

Eva Obarzanek, Ph.D., R.D.
Nutritionist
Prevention and Demonstration Research Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 604
7550 Wisconsin Avenue
Bethesda, MD  20892

Pauline S. Powers, M.D.
Professor of Psychiatry and Behavioral Medicine
Department of Psychiatry
College of Medicine
University of South Florida
3515 East Fletcher Avenue
Tampa, FL  33613

Cheryl Ritenbaugh, Ph.D., M.P.H.
Associate Professor
Department of Family and Community Medicine
University of Arizona
2231 East Speedway
Tucson, AZ  85719


Thomas Robinson, M.D., M.P.H.
Robert Wood Johnson Clinical Scholar
Director of Youth Studies
Stanford Center for Research in Disease Prevention
Stanford University School of Medicine
1000 Welch Road
Palo Alto, CA  94304

James F. Sallis, Jr., Ph.D.
Professor of Psychology
Department of Psychology
San Diego State University
6363 Alvarado Road, Suite 103-3
San Diego, CA  92128

Jeffery Sobal, Ph.D., M.P.H.
Associate Professor
Division of Nutritional Sciences
Cornell University
MVR Hall, Room 303
Ithaca, NY  14853

Bonnie Spring, Ph.D.
Professor
Psychology Department
University of the Health Sciences
Chicago Medical School
Building 51 
3333 Green Bay Road
North Chicago, IL  60064

Janice Williams, Ph.D.
Visiting Assistant Professor
Stanford Center for Research in Disease Prevention
Stanford University School of Medicine
1000 Welch Road
Palo Alto, CA  94304-1885


Peter Wood, D.Sc., Ph.D.
Professor of Medicine
Stanford Center for Research in Disease Prevention
730 Welch Road, Suite B
Palo Alto, CA  94304


NHLBI OEI TASK FORCE

Karen Donato, M.S., R.D.
Coordinator
NHLBI Obesity Education Initiative
Health Education Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892

Nancy Ernst, M.S., R.D.
Nutrition Coordinator for NHLBI
Office of the Director
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 204
7550 Wisconsin Avenue
Bethesda, MD  20892

Robert Garrison, M.S.
Chief 
Field Studies and Biometry Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 3A12
7550 Wisconsin Avenue
Bethesda, MD  20892

Millicent Higgins, M.D.
Associate Director
Epidemiology and Biometry Program
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 2C08
7550 Wisconsin Avenue
Bethesda, MD  20892

Dana Robin Hill, Ph.D.
Social Science Analyst
Behavioral Medicine Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 216
7550 Wisconsin Avenue
Bethesda, MD  20892

Michael J. Horan, M.D., Sc.M.
Associate Director for Cardiology
Division of Heart and Vascular Diseases
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 318
7550 Wisconsin Avenue
Bethesda, MD  20892

James Kiley, Ph.D.
Chief
Airways Diseases Branch
Division of Lung Diseases
National Heart, Lung, and Blood Institute
National Institutes of Health
Westwood Building, Room 6A15
5333 Westbard Avenue
Bethesda, MD  20892

Eva Obarzanek, Ph.D., R.D.
Nutritionist
Prevention, Demonstration, and Research Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 604
7550 Wisconsin Avenue
Bethesda, MD  20892


PARTICIPATING ORGANIZATIONS

American Academy of Family Physicians

Roger B. Rodrigue, M.D.
Chairman
Subcommittee on Public and Environmental Health
American Academy of Family Physicians
8880 Ward Parkway
Kansas City, MO  64114

American Academy of Pediatrics

William Dietz, M.D., Ph.D.
Director of Clinical Nutrition
Pediatric Gastroenterology and Nutrition
New England Medical Center Hospitals
750 Washington Street, Box 213
Boston, MA  02111

American Cancer Society

Daniel W. Nixon, M.D.
Vice President for Professional Education
American Cancer Society
1599 Clifton Road, N.E.
Atlanta, GA  30329

American Diabetes Association, Inc.

Phyllis M. Barrier, M.S., R.D., C.D.E.
Director, Council Affairs
American Diabetes Association, Inc.
National Service Center
1660 Duke Street
Alexandria, VA  22314

American Dietetic Association

Patricia Reeves, R.D.
Representative
American Dietetic Association
202 Kent Court
Jeffersonton, VA  22724

American Heart Association

Mary C. Winston, R.D., Ed.D.
Senior Science Consultant
Science Division
American Heart Association
Office of Scientific Affairs
7272 Greenville Avenue
Dallas, TX  75231

American Home Economics Association

Gladys Vaughn, Ph.D.
Director
Research and Education
American Home Economics Association
1555 King Street
Alexandria, VA  22314

American Society of Bariatric Physicians

Hal Seim, M.D., M.P.H.
Director CME
American Society of Bariatric Physicians
Professor
Department of Family Practice
University of Minnesota, 6-240 P.W.B.
Box 381 UMHC
Minneapolis, MN  55455

Association of State and Territorial
Public Health Nutrition Directors

Carol Loomis, M.S., M.P.H., L.D.
Diana Schmidt, M.P.H., L.D.
Representatives
Association of State and Territorial Public Health Nutrition
Directors
Maryland Department of Health and Mental Hygiene
201 West Preston Street
Baltimore, MD  21201

Centers for Disease Control and Prevention

Jeanne Creech, Ph.D.
Health Education Specialist
Community Health Promotion Branch
Centers for Disease Control and Prevention
4770 Buford Highway, NE (K-46)
Atlanta, GA  30341-3724

Sarah Kuester, M.S.
Public Health Nutritionist
Division of Nutrition
Centers for Disease Control and Prevention
4770 Buford Highway, NE (K-26)
Atlanta, GA  30341-3724

Julie Will, Ph.D., M.P.H.
Epidemiologist
Division of Diabetes Translation
Centers for Disease Control and Prevention
4770 Buford Highway, NE (K-10)
Atlanta, GA  30341-3724

David F. Williamson, Ph.D.
Epidemiologist
Division of Nutrition
Centers for Disease Control and Prevention
1600 Clifton Road, NE (K-26)
Atlanta, GA  30333

Council on Size and Weight Discrimination, Inc.

Nancy Summer
Council Director
Council on Size and Weight Discrimination, Inc.
P.O. Box 238
Columbia, MD  21045

Federal Trade Commission

Susan Cohn, J.D.
Attorney
Division of Advertising Practices
Bureau of Consumer Protection
Federal Trade Commission
601 Pennsylvania Avenue, N.W.
Washington, DC  20580

Food and Drug Administration

Alan Heaton, Ph.D.
Consumer Scientist
Division of Market Studies
Center for Food Safety and Applied Nutrition
Food and Drug Administration
200 C Street, SW (HFS-727)
Washington, DC  20204

Frederick N. Hyman, D.D.S., M.P.H.
Epidemiologist
Clinical Nutrition
Food and Drug Administration
200 C Street, SW (HFF-240)
Washington, DC  20204

Alan S. Levy, Ph.D.
Head of Consumer Research Staff
Division of Consumer Studies
Center for Food Safety and Applied Nutrition
Food and Drug Administration
200 C Street, SW (HFS-727)
Washington, DC  20204

Food Marketing Institute

Susan T. Borra, R.D.
Director
Consumer Affairs
Food Marketing Institute
800 Connecticut Avenue, NW
Washington, DC  20006

Health Resources Services Administration

Denise Sofka, M.P.H.
Nutrition Consultant
Maternal and Child Health
Health Resources and Services Administration
5600 Fishers Lane, Room 18A39
Rockville, MD  20857

Indian Health Service

Karen S. Strauss, M.S., R.D.
Chief
Nutrition and Dietetics
Indian Health Service
Parklawn Building, Room 6A-20
5600 Fishers Lane
Rockville, MD  20857

International Food Information Council

Claire Regan, M.S., R.D.
Director of Nutrition 
International Food Information Council
Suite 430
1100 Connecticut Avenue, NW
Washington, DC  20036

National Association for Sport and Physical Education

Paula Keyes Kun, M.S.
Director of Public Relations
National Association for Sport and Physical Education
1900 Association Drive
Reston, VA  22091

National Association to Advance Fat Acceptance

William Fabrey
Founder
National Association to Advance Fat Acceptance
P.O. Box 403 
Ivy, VA  22945

National Food Processors Association

Regina Hildwine, M.A.
Director
Technical Regulatory Affairs
National Food Processors Association
1401 New York Avenue, NW
Washington, DC  20005

National Institutes of Health--
National Cancer Institute

Carolyn Clifford, Ph.D.
Acting Chief 
Diet and Cancer Branch
National Cancer Institute
Executive Plaza North, Room 212
6130 Executive Boulevard
Rockville, MD  20852

National Institutes of Health--
National Institute of Child Health and
Human Development

Gilman D. Grave, M.D.
Chief
Endocrinology Nutrition and Growth Branch
National Institute of Child Health and Human Development
Executive Plaza North, Room 637
6130 Executive Boulevard
Rockville, MD  20852

Joel Killen, Ph.D.
Health Research Specialist
Prevention Research Branch
National Institute of Child Health and Human Development
6100 Executive Boulevard, Room 7B05-B
Rockville, MD  20852

National Institutes of Health--
National Institute of Diabetes and
Digestive and Kidney Diseases

Van S. Hubbard, M.D., Ph.D.
Director
Nutritional Sciences Branch
National Institute of Diabetes and Digestive and Kidney
Diseases
Westwood Building, Room 3A18B
5333 Westbard Avenue
Bethesda, MD  20892

Elizabeth H. Singer, M.S.
Director
Office of Health Research Reports
National Institute of Diabetes and Digestive and Kidney
Diseases
Building 31, Room 9A04
9000 Rockville Pike
Bethesda, MD  20892

Susan Yanovski, M.D.
Executive Secretary
National Task Force on Prevention and Treatment of Obesity
National Institute of Diabetes and Digestive and Kidney
Diseases
Building 10, Room 3S231
9000 Rockville Pike
Bethesda, MD  20892

National Institutes of Health--
Nutrition Coordinating Committee

Darla Danford, D.Sc., M.P.H., R.D.
Director
Division of Nutrition Research Coordination
National Institutes of Health
Building 31, Room 4B63
9000 Rockville Pike
Bethesda, MD  20892

National Institutes of Health--
Office of Minority Programs

Belinda Seto, Ph.D.
Deputy Director
Office of Minority Programs
National Institutes of Health
Building 1, Room 255
9000 Rockville Pike
Bethesda, MD  20892

National Recreation and Parks Association

Kathy Bartlett, C.L.P.
Northeast Regional Director
National Recreation and Parks Association
Suite 1
1800 Silas Deane Highway
Rocky Hill, CT  06067 

National School Health Education
Coalition, Inc.

Karen VanLandegham, M.P.H.
Director of Coalition Development
National School Health Education Coalition, Inc.
Suite 400 East
1001 G Street, NW
Washington, DC  20001

NHLBI Ad Hoc Committee on Minority Populations

Tanya Agurs, M.S., R.D.
Member
NHLBI Ad Hoc Committee on Minority Populations
2004 D Street, NE, Apt. 2
Washington, DC  20002

North American Association for the Study
of Obesity

Barbara C. Hansen, Ph.D.
Professor of Physiology
Obesity and Diabetes Research Center
School of Medicine
University of Maryland
10 South Pine Street, MSTF #600
Baltimore, MD  21201

President's Council on Physical Fitness and Sports

Eileen Conover
Representative
President's Council on Physical Fitness and Sports
Suite 250
701 Pennsylvania Avenue, NW
Washington, DC  20004

Society for Nutrition Education

Linda Smith, M.S.
Representative
Society for Nutrition Education
1220 Hemlock Street, NW
Washington, DC  20012

Society for Public Health Education

Gloria Nichols
c/o Donald Fedder, Dr.P.H.
Associate Professor and Director
Community Pharmacy Programs
University of Maryland School of Pharmacy
Campus for Professors
20 North Pine Street
Baltimore, MD  21201

U.S. Department of Agriculture--
Human Nutrition Information Service

Anne M. Shaw, Ph.D.
Nutritionist
Human Nutrition Information Service
6505 Belcrest Road, Room 353
Hyattsville, MD  20782

U.S. Department of Health and Human Services

Marilyn G. Stephenson, M.S., R.D.
Nutrition Advisor
Office of Disease Prevention and Health Promotion
Department of Health and Human Services
330 C Street, SW, Room 2132
Washington, DC  20201

U.S. Public Health Service--
Office of Minority Health

Betty Lee Hawks, M.A.
Associate Director
Division of Information Dissemination and External Liaison
Office of Minority Health
Rockwall II Building, Suite 800
5515 Security Lane
Rockville, MD  20852


OTHER PARTICIPATING GUESTS

Lilian Cheung, D.Sc., R.D.
Director
Harvard Nutrition and Fitness Project
Center for Health Communication
Harvard University School of Public Health
677 Huntington Avenue
Boston, MA  02115

Reva Frankle, M.S., R.D.
Private Consultant
323A Heritage Hills
Sommers, NY  18509

Jeanne Goldberg, Ph.D., R.D.
Assistant Professor of Nutrition
School of Nutrition
Tufts University
126 Curtis Street
Medford, MA  02155

Robert Hoerr, M.D., Ph.D.
Director
Optifast Program
Sandoz Nutrition Corporation
5100 Campbell Drive
St. Louis Park, MN  55416

Sue Y.S. Kimm, M.D., M.P.H.
Associate Professor for Clinical Epidemiology
University of Pittsburgh School of Medicine
432 Morewood Avenue
Pittsburgh, PA  15213


NHLBI STAFF 

P. Scott Allender, M.D.
Scientific Project Officer
Prevention and Demonstration Research Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 604
7550 Wisconsin Avenue
Bethesda, MD  20892

Matilde M. Alvarado, R.N., M.S.N.
Minority Health Specialist
Health Education Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892

Glen Bennett, M.P.H.
Coordinator
NHLBI Smoking Education Program
Health Education Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892

Joan E. Blair, R.N., M.P.H.
Coordinator
Women's Health/Workplace Initiative
Health Education Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892

Clarice Brown, M.S.
Coordinator
Data Analysis and Program Evaluation
Health Education Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892

James Cleeman, M.D.
Coordinator
National Cholesterol Education Program
Office of the Director
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A05
9000 Rockville Pike
Bethesda, MD  20892

Jeffrey A. Cutler, M.D., M.P.H.
Chief
Prevention and Demonstration Research Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 604
7550 Wisconsin Avenue
Bethesda, MD  20892

Marguerite Evans, M.S., R.D.
Nutritionist
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 604
7550 Wisconsin Avenue
Bethesda, MD  20892

Richard R. Fabsitz, M.A.
Senior Research Investigator
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 3A17
7550 Wisconsin Avenue
Bethesda, MD  20892

Mary McDonald Hand, R.N., M.S.
Coordinator
National Heart Attack Alert Program
Health Education Branch
Office of Prevention, Education and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892 

Keith Hewitt
Chief
Information Services Section
Communications and Public Information Branch
Office of Prevention, Education, and Control 
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A21
9000 Rockville Pike
Bethesda, MD  20892

Claude Lenfant, M.D.
Director
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 5A52
9000 Rockville Pike
Bethesda, MD  20892

Terry Long
Chief
Communications and Public Information Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A21
9000 Rockville Pike
Bethesda, MD  20892

Gregory Morosco, Ph.D., M.P.H.
Chief
Health Education Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A03
9000 Rockville Pike
Bethesda, MD  20892

Eileen P. Newman, M.S., R.D.
Nutrition Education Advisor
Health Education Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892

Nancy J. Poole
Chief of Program Operations
Office of the Director
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A18
9000 Rockville Pike
Bethesda, MD  20892

Edward J. Roccella, Ph.D., M.P.H.
Coordinator
National High Blood Pressure Education Program
Office of the Director
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A05
9000 Rockville Pike
Bethesda, MD  20892

Denise G. Simons-Morton, M.D., Ph.D.
Medical Officer
Prevention and Demonstration Research Branch
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 604
7550 Wisconsin Avenue
Bethesda, MD  20892

Elaine Stone, Ph.D., M.P.H.
Program Administrator
Child and Adolescent Trial for Cardiovascular Health (CATCH)
Division of Epidemiology and Clinical Applications
National Heart, Lung, and Blood Institute
National Institutes of Health
Federal Building, Room 604A
7550 Wisconsin Avenue
Bethesda, MD  20892

Diane Striar
Senior Press Liaison
Communications and Public Information Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A21
9000 Rockville Pike
Bethesda, MD  20892

Louise Williams
Public Affairs Specialist
Communications and Public Information Branch
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A21
9000 Rockville Pike
Bethesda, MD  20892

Richard A. Windsor, Ph.D., M.P.H.
Former Director
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Building 31, Room 4A16
9000 Rockville Pike
Bethesda, MD  20892

SUPPORT STAFF

Patricia Moriarty, M.Ed., R.D.
NHLBI OEI Manager
R.O.W. Sciences, Inc.
1700 Research Boulevard
Rockville, MD  20850

Anne Melly, M.S., R.D.
University Research Corporation
7200 Wisconsin Avenue
Bethesda, MD  20814



TABLE OF CONTENTS



          EXECUTIVE SUMMARY

     I.   INTRODUCTION

     II.  WORKSHOP OBJECTIVES

     III. PANEL PRESENTATIONS

          Panel 1:  The Epidemiology of Obesity and
Cardiovascular Disease
               Introduction
               Obesity in Children
               Obesity in Adults
               General Discussion
               References

          Panel 2:  Strategies for Obesity Prevention
               Introduction
               School-Based Obesity Programs
               Family-Based Obesity Programs
               Community-Based Obesity Programs
               General Discussion
               References

          Panel 3:  Issues in Educating the Public About
Weight and Obesity
               Introduction
               Nutrition in Adolescence:  Obesity and the
Hazards of Treatment Smoking and Weight

               The Role of Physical Activity in the
Prevention and Management of Obesity
               Sociocultural Aspects of Obesity
               General Discussion
               References     

          Panel 4:  Communication Strategies for Educating
the Public
               Introduction and Overview
               Audience Segmentation as a Strategy for
Targeting Adults
               Communication Strategies for Targeting
Children and Adolescents
               References     

     IV.  SMALL GROUP REPORTS

          Small Group Report:  Children
          Small Group Report:  Adolescents
          Small Group Report:  Adults
          Small Group Report:  Older Adults
          Small Group Report:  Minority Populations



EXECUTIVE SUMMARY


     In the United States, the prevalence of obesity has
been on the rise despite an increasing preoccupation with
weight loss.  According to preliminary data from the 1988-91
National Health and Nutrition Examination Survey (NHANES
III),* the prevalence of overweight has increased from 25 to
33 percent during the past 10 years.  The age-adjusted
prevalence of overweight is 32 percent for men and 35
percent for women, compared with 24 percent for men and 27
percent for women in the NHANES II (1976-80).  Although the
NHANES III has yet to be analyzed for children, the NHANES I
(1971-74) and the NHANES II both documented an increasing
prevalence of obesity in children ages 6-17 years.

     Obesity contributes to at least half the chronic
diseases in Western societies.  Heart disease remains the
number one killer of Americans, and obesity or overweight is
known to influence the impact of this disease on the
population.  Obesity is associated with an increased risk
for hypertension, diabetes, high total blood cholesterol,
and low high density lipoprotein (HDL) cholesterol.  Obesity
is also an independent risk factor for coronary heart
disease.  In some studies, even mild to moderate overweight
is associated with a substantial elevation in coronary risk. 
Other studies show the effects of weight gain to be
dependent on the age of onset.

     A more complex issue is the relationship of weight and
weight loss to all-cause mortality.  Various studies
demonstrate a U- or J-shaped curve with the highest and
lowest levels of weight associated with the greatest
mortality.  Although studies show weight loss to be
associated with improvements in blood pressure and blood
cholesterol levels, weight loss also has been shown to be
associated with higher mortality.  It is unclear whether
weight loss is causally related to the increase in mortality
or weight loss and mortality are a consequence of illness.

     Millions of overweight Americans who are attempting to
lose weight often are unsuccessful over the long term.  Data
show that many individuals regain one-third to two-thirds of
intentionally lost weight within 1 year and regain the rest
of the weight within 5 years.  In addition, many people are
engaging in weight loss practices without the necessary
medical supervision or monitoring.

     The problem of obesity and overweight is multifaceted
and involves complex questions that have no simple
solutions.  Attention needs to be focused on a variety of
fronts, from the standpoint of treatment for those thousands
of Americans who suffer from this condition and are at
increased risk for not only heart disease but other diseases
as well.  Efforts to help prevent obesity in both children
and adults must begin to help alleviate much of the pain and
suffering that ultimately result.


PANEL 1:  THE EPIDEMIOLOGY OF OBESITY AND CARDIOVASCULAR
DISEASE

Obesity in Children

     Consensus has yet to be reached on both a standard
definition and a standard measurement technique for
determining obesity in children.  Definitions used for
adults cannot easily be applied to children.  Because
childhood obesity does appear to track into adulthood and
obesity is related to elevated cardiovascular risk factors
in children, health consequences are associated with
childhood obesity.

     Etiology of obesity in childhood is complex and
involves genetic, dietary, physical activity, and
socioeconomic factors.  Longitudinal studies with consistent
use of the various measures to determine obesity would
provide a better understanding of the etiology of obesity in
children.

Obesity in Adults

     The lack of a standard definition and standard
measurement technique for determining overweight and obesity
in adults makes it difficult to assess the impact of excess
weight on health accurately.  The NHANES data and definition
provide a reference base for comparing studies and examining
trends.

     The latest data from the NHANES III indicate that
approximately one-third of the U.S. adult population (ages
20 to 74) is overweight (defined as body mass index greater
than or equal to 27.8 for men and greater than or equal to
27.3 for women; these cutpoints represent the sex-specific
85th percentiles for persons ages 20 to 29 in the NHANES
II).  Adult obesity in the United States has been increasing
in both men and women and in both African Americans and
whites.  Overweight is disproportionately higher in
African-American and Mexican-American women.  The
age-adjusted prevalence of overweight is 50 percent among
African-American women and 48 percent among Mexican-
American women,compared to 33 percent among white women.

     Obesity is related to elevated cardiovascular risk and
to mortality.  Furthermore, weight gain exacerbates
cardiovascular risk factors whereas weight loss improves
these conditions.  Maintaining weight loss over the long
term, however, is difficult.

     Race, education, parity, acculturation, physical
activity, caloric intake, and genetics are the etiologic
factors that need to be considered.  Increased attention to
the prevention of obesity in early adulthood is needed, but
determining what recommendations should be given to already
obese adults is an equally great challenge.


PANEL 2:  STRATEGIES FOR OBESITY PREVENTION

     Interventions to help prevent obesity have included a
variety of settings such as schools, clinics, families,
communities, and other populationwide approaches. 
Interventions of this nature often consider age, gender,
ethnicity, and geographic location.

School-Based Obesity Programs

     School-based obesity programs offer the opportunity to
reach a large number of children, especially younger
children, on a daily basis for a number of years.  They also
offer multiple opportunities through the physical education
curriculum, the school lunch program, other environmental
changes, and the summer school program.  School programs
could tackle both prevention and treatment issues with
complementary strategies and could initiate health education
services for peer groups, families, and school staff.  An
important consideration for school-based programs is whether
comprehensive programs can be implemented successfully over
the long term in schools that already face limited
resources.  Nevertheless, schools remain an important
vehicle for influencing the environment of many children.

Family-Based Obesity Programs

     Family-based obesity programs in which both generations
and all family members participate present a promising
avenue for the prevention and treatment of obesity. 
Variables such as diet, food availability, and family
environment including activity level and behavioral support
can be manipulated so that the largest possible impact is
felt by children and parents.  Family-based obesity programs
target the family's behaviors and environment and ensure
that parents play an active role in the intervention.

Community-Based Obesity Programs

     Because the problem of obesity is pervasive, affecting
all segments of the population regardless of age, race, or
gender, it can be viewed as a community problem that
requires community-based interventions that can bring about
change.  Community-based programs potentially can reach
large numbers of individuals at a reasonable cost.


PANEL 3:  ISSUES IN EDUCATING THE PUBLIC ABOUT WEIGHT AND
OBESITY

     Cultural factors influence knowledge, attitudes, and
behaviors regarding food consumption and activity patterns
and thus can influence weight and even body shape.  Our
culture currently places greater emphasis on the food intake
side of the energy balance equation, with limited importance
given to energy expenditure.  In fact, our language is
deficient in terms to describe the desire to engage in
physical activity.  Language as well as many other cultural
factors should be examined closely when educating the public
about weight and obesity. 

Smoking and Weight

     Smoking and body weight have been linked for many
years; many people who begin smoking lose weight, whereas
many who quit smoking gain weight.  The concern about weight
for smokers can predict in part their success at quitting;
current smokers are much more likely than ex-smokers to
consider weight loss as important.  If individuals do not
expect weight gain after quitting smoking, they are more
likely to quit.  Therefore, public messages related to
weight and smoking need to communicate the relative risks
related to smoking versus the weight gain associated with
cessation.  Particular target audiences for messages are
adolescent females and adult women.

The Role of Physical Activity in the Prevention and
Management of Obesity 

     Modest increases in physical activity appear to assist
weight control and offers other benefits such as changes in
body composition, psychological well-being, and reduced
risks for cardiovascular disease.  Increased physical
activity and improved fitness also contribute to an improved
quality of life, particularly during aging.

     Both the general population and obese individuals,
however, report numerous barriers to regular exercise, such
as perceived lack of time, boredom, embarrassment, and
inaccessibility of facilities.  Ways of encouraging the
public to incorporate physical activity into daily routines
need to be explored.

Sociocultural Aspects of Obesity

     Viewing obesity in the larger context of social and
cultural values provides possibly the most important
insights into the underlying factors.  Social patterns,
social explanations, and social consequences of obesity are
all important considerations.

     Social development--helping societies change their
value systems about thinness, physical activity, and low-fat
diets--may be an important intervention goal.  Education,
resources, and the environment might be the best
interventions.  Insights and interventions from sociology
would aid in efforts at dealing with obesity in the society.


PANEL 4:  COMMUNICATION STRATEGIES FOR EDUCATING THE
          PUBLIC

     Communicating messages to various audiences as part of
a broad-based information campaign requires a multistage
process.  A communication strategy statement needs to be
developed to summarize the health problem, identify primary
and secondary target audiences, and develop possible
messages and appropriate channels for the various target
audiences.  Success at communicating messages to the wide
variety of audiences is more likely if multiple levels of
social organizations are targeted.  The most successful
communication campaigns have used multiple yet complementary
educational strategies.

Targeting Adults

     Social marketing strategies are being used increasingly
in health education to promote attitudes, behaviors, and
lifestyles that can prevent illness or minimize its
consequences.  One important social marketing strategy is
audience segmentation that permits a large, undifferentiated
group to be broken down into smaller, homogeneous subgroups
based on lifestyles, values, attitudes, behaviors, or other
characteristics.  This type of analysis allows campaign
planners to better understand their target audience and
therefore to better communicate appropriate messages to
them.

Targeting Children and Adolescents

     In terms of public education, a population-based
approach rather than an individualized approach for
high-risk audiences appears to be the most appropriate
communication strategy for reaching obese children and
adolescents.  Healthful eating and physical activity should
be emphasized rather than dieting.  It is impossible to
predict with certainty which children are at particularly
high risk.  Thus, different yet complementary educational
strategies are essential to getting the message out to
various target groups.  Because of possible adverse effects
from any type of communication campaign, some form of
evaluation should be incorporated from the start.

SMALL GROUP REPORTS

     Five potential target audiences for the educational
messages from the National Heart, Lung, and Blood Institute
Obesity Education Initiative (NHLBI OEI) were
identified--children, adolescents, adults, older adults, 
and minority populations.  Small groups discussed each of
these audiences in terms of their unique characteristics,
particularly as they relate to issues of weight or 
patterns of eating and physical activity.  For each target
audience, the small groups addressed content-appropriate
messages, source credibility in the delivery of messages,
motivational strategies that encourage action, and
appropriate communication channels to deliver messages.

Small Group Report:  Children

     The entire population of children ages 2 to 11 was
identified as the priority target audience for a
population-based approach to primary prevention.  This
approach was more acceptable than targeting high-risk obese
children to avoid possibly increasing chronic dieting and
eating disorders as well as stigmatizing obese children. 
Messages should be tailored to the various developmental
stages of children, and messages should be targeted
simultaneously to those who influence children.  Messages
for children at high risk need to be developed separately
and carefully.

     Two major public health messages were recommended for
this priority target audience:  (1) be more active and (2)
eat less fat and eat healthier.  A variety of ways to convey
this information were suggested.

     Small Group Report:  Adolescents

     As with children, the entire adolescent population
(ages 11 to 17) was identified as the priority target
audience with the emphasis on primary prevention.  Again,
concern was raised regarding national messages on obesity
and weight that might further stigmatize high-risk
adolescents.

     The importance of healthy eating combined with physical
activity should be the cornerstone message not only focusing
on preventing obesity but on other potential health benefits
as well.  The idea that there is a broad range of safe
weights and acceptable shapes also needs to be conveyed.

     In terms of credible sources, peer groups have the most
powerful influence on adolescents.  Parents, role models,
various members of the school staff, health providers, and
the Government are also influential and could be used to
educate adolescents and groups that communicate to
adolescents.

     A variety of motivational strategies and appropriate
channels of communication were suggested to encourage
healthy eating and physical activity.  However, to improve
and enhance the effectiveness of messages and strategies
targeted to adolescents, formative evaluation and research
are needed regarding their health knowledge, the
effectiveness of different messages, and the various methods
of communication that produce the desired outcomes.

Small Group Report:  Adults

     All men and women, ages 18 to 65, particularly those of
low socioeconomic status and with low education levels, were
identified as the primary target audiences.  Messages to
these different audiences must encourage healthy eating
behaviors and increased physical activity and must emphasize
that weight gain is an unrecognized health hazard as people
get older.

     Suggested strategies to reach these audiences ranged
from the need for messages to be simple, positive, and
attainable, to the need for environmental changes in
restaurants and supermarkets.  Health care providers and
organizations were cited as a particularly credible sources
that need to provide more information about issues related
to weight.

Small Group Report:  Older Adults

     Americans over age 65 are a growing segment of the
population.  Overall characteristics of older adults include
a preponderance of women, a broad range of educational
levels and socioeconomic status, more leisure time, and a
desire to remain independent.  Advancing age also may bring
decreased mobility, a decline in physical functions, higher
rates of chronic disease, malnutrition, and social
isolation.  

     Concern or lack of concern among older adults about
overweight must be put into the context of many other,
perhaps more urgent, health issues.  Older adults are less
likely to be concerned about overweight and more likely to
be concerned about undesired weight loss.  Among this
population, there is greater concern about health and less
concern about appearance.

     Physical activity for older adults was noted as very
important for many reasons including maintaining lean body
mass and bone density and preserving strength and endurance. 
However, older adults have greater difficulty exercising
combined with a great fear of injury.

     Motivational strategies for older adults need to
consider numerous factors including health status, cultural
differences, climatic and environmental concerns, fear of
ill health, and cost.  Suggested channels of communication
included many advocacy, volunteer, and health organizations
that address issues pertinent to older adults.

Small Group Report:  Minority Populations

     The four major minority populations in the United
States--African Americans, Hispanic Americans, Asians and
Pacific Islanders, and Native Americans--are the fastest
growing segments in the total U.S. population.  These groups
also tend to exhibit similar demographic characteristics
such as high poverty rates, high high-school dropout rates,
limited access to health care and food, high levels of risk
factors and incidence of disease, and variant health
knowledge and practices.

     African-American women, ages 20 to 25, should be a
priority target audience because of the particularly high
prevalence of overweight and obesity in African- American
women.  Adolescent African-American girls also should be a
priority target--in terms of primary prevention--because
excessive weight for this population begins around puberty. 
The other minority groups also were noted as important
targets of information concerning primary prevention of
overweight.

     Because of traditional gender roles and strong family
units prominent in minority cultures, messages about healthy
eating should target women and messages about physical
activity should target men.  The overall goal should be to
give these populations a sense of empowerment and to
increase their self-esteem.

     In developing messages for different minority groups,
it is essential to segment populations according to country
of origin, how long they have been in the United States, and
their degree of acculturation.  Education efforts should
begin with a campaign to raise awareness, followed by
targeting individual lifestyles for change.

REFERENCE

Naitonal Center for Health Statistics.  Health, United
States, 1993.  Hyattsville, MD:  Centers for Disease Control
and Prevention; 1994.




INTRODUCTION


     The National Heart, Lung, and Blood Institute (NHLBI)
has been a leader in developing and fostering educational
messages, materials, and activities and disseminating them
to both health care providers and the public to help reduce
cardiovascular disease (CVD) morbidity and mortality.  These
educational activities evolve from the wide array of
research investigations supported by the NHLBI, ranging from
basic science at the cellular level to education and
demonstration studies carried out in communities.

     For several decades, NHLBI-supported research on
obesity has been fundamental to the understanding of
overweight and obesity as they contribute to the
cardiovascular disease burden of the Nation.  The health
implications of obesity have been documented and include an
independent increased risk for CVD as well as increased
risks for hypertension, diabetes, hypertriglyceridemia, low
levels of high density lipoprotein (HDL) cholesterol, and
high levels of total and low density lipoprotein (LDL)
cholesterol.  Sleep apnea and impaired lung function, gall
bladder disease, gout, and degenerative joint disease or
osteoarthritis can occur with more severe obesity.  In
addition, obesity is associated with an increased mortality
from certain types of cancer.  The distribution of body fat
(upper body versus lower body) appears to influence these
health risks as well.  For some, the psychological burden of
obesity is more distressing than the physical consequences
combined.

     Based on this research and recognizing obesity as a
major public health concern, Dr. Claude Lenfant, NHLBI
director, inaugurated the NHLBI Obesity Education Initiative
(NHLBI OEI) in January 1991.  It is one of seven education
programs coordinated by the Office of Prevention, Education,
and Control.  All of these programs are built on three
foundations:  a strong scientific basis; consensus building
from a wide variety of professional organizations; and
communications to targeted communities, patients, health
care providers, and special populations such as minority
groups or individuals with lower reading skills. 

     Accordingly, the Strategy Development Workshop for
Public Education on Weight and Obesity, held on September
24-25, 1992 in Bethesda, Maryland, brought together leading
experts from various areas of obesity research,
communication specialists, and representatives from 37
professional organizations and Federal agencies.  As the
first major activity sponsored by the OEI, this workshop
sought to address some of the important educational
challenges related to weight control and CVD.  Karen Donato,
coordinator of the NHLBI OEI, welcomed participants, guests,
and NHLBI colleagues to the workshop and provided background
on the initiative, the objectives of the workshop, and the
charge to the working groups.

     The OEI was established by the Institute because of
strong scientific evidence and need for educational messages
and activities.  The National High Blood Pressure Education
Program (NHBPEP) was the first national education program,
established in 1972.  The Institute, in subsequent years,
established four other national education programs based on
the NHBPEP model.  They include the National Cholesterol
Education Program, the National Blood Resource Education
Program, the National Asthma Education and Prevention
Program, and the National Heart Attack Alert Program.  In
addition, the Institute has developed other types of
educational programs and initiatives including the NHLBI
Smoking Education Program and the NHLBI Obesity Education
Initiative.

     Because many of the NHLBI education programs deal with
obesity-related issues, the OEI has been designed to
coordinate and enhance obesity education activities across
the national education programs, to take steps to advance
the understanding of the complicated issues involved, and to
promote additional research needed to clarify some of the
questions that remain.  It also takes into account the keen
interest of the NHLBI Ad Hoc Committee on Minority
Populations on obesity-related health concerns of diverse
minority groups in this country.  

     The OEI also has recognized the need to work toward
achieving the Healthy People 2000 Objectives for the Nation
related to reducing the prevalence of overweight in the
United States.  One specific objective calls for a concerted
effort to prevent the development of overweight in general,
while facilitating weight reduction among the overweight. 
Five other national objectives focus on the impact of
dietary habits and physical activity on the prevention of
overweight.

     The OEI differs from the other NHLBI education programs
in that it does not have a coordinating committee composed
of numerous professional organizations.  Instead, the OEI
consists of a task force with representatives from the
various research divisions of the Institute, many of whom
play important roles in the other national education
programs and thus help ensure consistent messages across
programs.  The task force also convenes special ad hoc
expert advisory panels to address specific issues and to
help guide the initiative.  In fact, this workshop evolved
from planning meetings held in August 1991 in which a group
of experts discussed the determinants, consequences, and
treatment issues related to obesity.  Based on the
recommendations from the planning meetings, the initiative
has taken on both a high-risk strategy and a
population-based
strategy to educate professionals and the public. 
Both strategies are important in the management of obesity.

     The high-risk strategy targets individuals who are
experiencing, or who are at high risk for, the adverse
health effects and medical complications associated with
obesity.  In implementing the high-risk strategy, an expert
panel will address the issues related to the identification,
evaluation, and treatment of obesity, specifically in
individuals with other risk factors for CVD and lung
problems.

     The population-based strategy focuses on the prevention
of obesity and its complications in the general public. 
From the many surveys already conducted, it is clear that
the public has not only heard about weight control and
obesity but has been inundated with information.  However,
the media often foster sociocultural ideals regarding body
weight and physical appearance that are unrealistic for most
people.  In many instances, the messages that get
communicated are not always accurate or realistic and often
leave the public confused and vulnerable.  

     Voluntary weight loss attempts by large segments of the
American population are now typical.  The National
Institutes of Health (NIH) Technology Assessment Conference
on Methods for Voluntary Weight Loss and Control was held in
1992.  The experts also reported that one-third of the
population is overweight, and as many as 40 percent of women
and 24 percent of men are trying to lose weight at any one
time.  The panel noted that a distressing health paradox now
exists in American society.  On the one hand, the pursuit of
thinness has led many people, particularly young women, who
do not need to lose weight to engage in weight loss
practices; on the other hand, treatment methods have failed
those people who might otherwise have benefited from weight
reduction.

     Because the issues surrounding obesity and overweight
are complex and because the consequences of confusion can be
serious, reaching a consensus on the messages that should be
communicated and the audiences that should be targeted is
imperative.  The purpose of the NHLBI OEI is to educate the
public about the relationship of overweight and physical
inactivity to heart disease and lung function.  The Strategy
Development Workshop for Public Education on Weight and
Obesity was convened to help devise an effective
population-based strategy that would take into account the
public's current perceptions, knowledge, attitudes, and
behaviors regarding body weight in the hope of exerting a
positive impact on reducing the high prevalence of obesity.



WORKSHOP OBJECTIVES

     The purpose of the Strategy Development Workshop for
Public Education on Weight and Obesity was to involve a
group of knowledgeable professionals in a collaborative
planning process to assist in identifying educational
opportunities that could become part of a public education
effort on obesity prevention.  Four expert panel
presentations followed by large and small group discussions
provided the structure for the workshop.  Participants were
asked to consider:

o    the issues in educating the public about weight and
physical activity and their relationship to cardiovascular
and lung diseases;

o    the priority target audiences for the NHLBI Obesity
Education Initiative;

o    the education needs of each target audience in terms of
basic knowledge, skills, and behaviors regarding weight,
overweight and obesity, and physical activity, and their
relationship to cardiovascular and lung diseases;

o    the public education approaches that would most
effectively communicate the information, attitudes, and
skills that members of each target audience need in order to
change their behaviors regarding weight, physical activity,
and eating patterns; and

o    the communication channels that are appropriate for
reaching each target audience and the roles that a wide
range of organizations can play in disseminating public
education messages and in developing local educational
program activities.

     This report summarizes the activities of the workshop.


PANEL PRESENTATIONS


     Panel 1:  The Epidemiology of Obesity and
Cardiovascular Disease

     Panel 2:  Strategies for Obesity Prevention

     Panel 3:  Issues in Educating the Public About Weight
and Obesity

     Panel 4:  Communication Strategies for Educating the
Public



PANEL 1:  THE EPIDEMIOLOGY OF OBESITY AND CARDIOVASCULAR
DISEASE

     The panel on the epidemiology of obesity and
cardiovascular disease was chaired by Dr. JoAnn E. Manson,
Brigham and Women's Hospital and Harvard Medical School. 
She provided an overview of the extent and complexity of the
problem.  Dr. Eva Obarzanek, NHLBI Division of Epidemiology
and Clinical Applications, examined obesity in children by
looking at definition and measurement issues, the health
consequences related to cardiovascular risk factors, and
etiological complexities.  Dr. Diane Bild, NHLBI Division of
Epidemiology and Clinical Applications, focused on obesity
in adults and discussed health risks as well as demographic
and etiological factors related to obesity.  The panel
concluded with general discussion and comments by attendees.


INTRODUCTION--JoAnn E. Manson, M.D., Dr.P.H.

     Obesity contributes to at least half the chronic
diseases in Western societies.  In the United States, the
prevalence of obesity has been slowly increasing despite an
increasing preoccupation with weight loss.  For
African-American women, the prevalence of obesity is
approaching near epidemic proportions (National Center for
Health Statistics, 1987).

     Long-term success rates of weight loss efforts are
equally discouraging.  Data presented at the NIH Technology
Assessment Conference on Methods for Voluntary Weight Loss
and Control in March 1992 showed that many individuals
regain one-third to two-thirds of intentionally lost weight
within 1 year, with the rest of the weight returning within
5 years (National Institutes of Health, 1992).


     Statistics also support an increasing prevalence of
obesity in the United States in children ages 6 to 11 years
and a similar increase in children ages 12 to 17 years. 
Physical inactivity and diet appear to be leading
contributing factors.  According to Morbidity and Mortality
Weekly Report, only 35 percent of U.S. high school students
attend physical education classes daily, and only 13 percent
consume the recommended five daily servings of fruits and
vegetables (Centers for Disease Control, 1992).

     Obesity's association with insulin resistance--often
referred to as syndrome X--is characterized by an elevated
risk of glucose intolerance, high insulin levels, increased
very low density lipoproteins (VLDL), elevated
triglycerides, decreased HDL-cholesterol levels, and high
blood pressure.  Individuals at particularly high risk for
this syndrome are those with abdominal obesity, or a
waist-to-hip
ratio of greater than 0.95 in men and greater than
0.80 in women (Bjorntorp, 1985).

     Various studies have linked body weight and mortality. 
An increased risk of all-cause mortality among the obese was
demonstrated in the 1959 Build and Blood Pressure Study, the
1979 Build Study, and the 1979 American Cancer Society Study
(Society of Actuaries, 1959; Society of Actuaries and
Association of Life Insurance Medical Directors of America,
1980; Lew and Garfinkel, 1979).  However, these same studies
also showed a J-shaped curve, or an increasing risk of
mortality among the lean. 

     Cigarette smoking has been cited as one of the
confounders in most previous studies because smoking is
associated with lower body weight as well as increased
mortality.  Twenty-six-year followup data on Seventh-Day
Adventists showed a clear linear association between body
weight and all-cause mortality, with the leanest men having
the lowest mortality (Lindsted et al., 1991).  More research
is required in this area to determine whether any health
risks are associated with leanness as well as the magnitude
of the risk associated with mild-to-moderate obesity (Manson
et al., 1987).

     Prevention and treatment of obesity in children and
adults involves complex questions that have no simple
solutions.  Of primary importance, attention needs to focus
on the prevention of obesity in both children and adults.


OBESITY IN CHILDREN--Eva Obarzanek, Ph.D., R.D.

     Describing the extent of the problem of obesity in
children involves not only examination of the prevalence and
distribution of obesity through childhood, but also
consideration of its definition and measurement,
relationship to cardiovascular risk factors, tracking into
adulthood, and etiology.  The following sections explore
some of these complex issues.

Definition and Measurement Issues

     The two main difficulties of accurately describing the
epidemiology of obesity in children are related to issues of
definition and measurement.  Different methods of measuring
obesity yield different results, different definitions, and
different interpretations of the cardiovascular risks of
pediatric obesity.

     Weight alone is not a good measure of obesity because
of its dependency on height.  Body mass index (BMI, kg/m2)
has been used extensively in epidemiological studies because
it is a measure of weight that is relatively independent of
height, can be measured easily, and appears to be moderately
well correlated with body fat in adults and children.  For
growing children, however, the interpretation of BMI is more
of a problem because the rate of weight gain may not be in
step with the rate of height gain.  This means that BMI may
fluctuate as children are tracked during their growing
years.  BMI also carries with it components of frame size
and lean body mass that greatly increase--more so than
fat--during childhood.

     A second measure frequently used to assess obesity is
skinfold thickness.  Skinfold measures have the advantage of
being direct measures of fat; however, compared to measures
of height and weight, they are less easily and less reliably
measured.

     The 1976-80 National Health and Nutrition Examination
Survey (NHANES II) (National Center for Health Statistics,
1987) data for 7,000 children between the ages of 2 and 18
years indicated that for both boys and girls BMI declines
slightly in the early years and then begins to increase
throughout the teenage years (figures 1 and 2).  On the
other hand, when body fat was measured using triceps
skinfold (TSF) measurements, the results differ.  For both
boys and girls, TSF measures increase from early childhood
through puberty, ages 9 to 12; TSF measures then decline
during the teenage years for boys but continue to rise for
girls (figures 3 and 4).

     Ethnic differences in TSF measures are evident in
comparing the NHANES II data and the 1982-84 Hispanic Health
and Nutrition Examination Survey (HHANES) data (National
Center for Health Statistics, 1989).  From age 2 through the
teenage years, TSF measures were lower for African-American
boys, and similar or slightly higher for Mexican-American
boys, than they were for white boys.  In all age groups, TSF
measures for African-American girls were lower than they
were for white girls, until the teenage years when they
become larger than for white girls.  For Mexican-American
girls, TSF measures were similar or slightly higher than
those of white girls.

Prevalence Data

     In children, obesity--characterized by excess body
fat--is often defined as greater than or equal to the 85th
percentile for age and sex of TSF or BMI.  Using the 85th
percentile of TSF as a definition, Gortmaker and associates
(1987) compared data from the Health Examination Surveys
(HES) of the 1960s, the NHANES I (1971-74) and the NHANES II
(1976-80) data.  Using the HES as the reference population,
across each succeeding survey, they found the prevalence of
obesity increasing among children (figure 5).  The NHANES II
data showed the prevalence of obesity in children ages 6 to
11 years at 27 percent--an increase of 20 percent from the
NHANES I--whereas in 12- to 17-year-olds, the prevalence of
obesity was about 22 percent--an increase of about 9
percent.  Data from the Bogalusa Heart Study also showed an
increase in the prevalence of obesity, defined as the 85th
percentile of the ponderal index (kg/m3), from 15 percent in
1973 to approximately 24 percent in 1984 in children ages 5
to 14 years (Shear et al., 1988).

     More recent work, however, has shown that the 85th
percentile of TSF may not be indicative of obesity in all
cases because a given percentile represents different levels
of body fat at different ages (Lohman et al., 1989).  For
example, the 85th percentile of TSF for boys at age 6
corresponds to 15-percent body fat, whereas for boys at age
12, the 85th percentile corresponds to 23-percent body fat. 
To adjust for this, Lohman and colleagues proposed using
percent body fat rather than percentiles of skinfolds or BMI
to define obesity (Williams et al., 1992).  They defined
pediatric obesity as a body fat level greater than or equal
to 25 percent for boys and greater than or equal to 30
percent for girls, derived from prediction equations using
triceps and subscapular skinfolds, discussed later. 
Applying this definition to the NHANES II triceps and
subscapular skinfolds data, the prevalence of obesity
increases around the pubertal years for both boys and girls. 
The prevalence in obesity then declines sharply for boys
throughout the teenage years but falls only slightly for
girls.

     Figure 6 compares the prevalence of obesity in children
(NHANES II data) using the TSF percentile method versus the
percent body fat method.  In children ages 6 to 11 years,
the prevalence of obesity is 27 percent when using the 85th
percentile of TSF definition compared to 11 percent when
using the percent body fat definition.  Similarly, for
teenagers ages 12 to 17 years, the prevalence of obesity is
22 percent when the percentile method is used compared to
nearly 14 percent when the percent body fat method is used. 
Further validation of percent body fat standards is
required.


Tracking of Obesity

     One of the health concerns regarding obesity in
childhood is that obesity may continue into adulthood. 
Longitudinal studies have suggested that, although not all
obese children become obese adults, obese children have a
greater probability of remaining obese than would be
expected by chance (Garn and LaVelle, 1985).  In the
Bogalusa Heart Study, for example, 49 percent of children
ages 5 to 14 years who were initially obese (in the 90th
percentile of TSF measurements) were obese in the 5-year
followup, and 43 percent remained obese in the 8-year
followup (Freedman et al., 1987).  In the Tecumseh Community
Health Survey, 26 percent remained obese after 20 years
(Garn and LaVelle, 1985).  This risk of remaining obese
appears to be greater when obesity occurs later in childhood
(Harsha et al., 1987).  More research on the tracking of
obesity is needed.

Relation to Cardiovascular Risk Factors

     Studies have linked health consequences, including the
development of risk factors for CVD, with childhood obesity
(Aristimuno et al., 1984).  Children who gain the most
weight have the greatest increase in cardiovascular risk
factors, and children in the upper quintile of body weight
are more likely to develop two or more cardiovascular risk
factors (Smoak et al., 1987).  In addition, data from the
Bogalusa Heart Study showed that central body fat (as
measured by suprailiac and subscapular skinfold thickness)
is related to adverse lipid profiles, independent of overall
body fat (Freedman et al., 1989).  Similar results also were
found for blood pressure (Shear et al., 1988).

     Lohman and colleagues, using their proposed definition
of obesity as percent body fat, have tried to determine a
cut point or level of body fat that is associated with
elevations in cardiovascular risk factors in children
(Williams et al., 1992).  If no relationship existed between
obesity and cardiovascular risk factors, 20 percent of all
children across all quintiles of percent body fat would
develop high blood pressure.  However, Lohman determined
that 35 percent of boys were in the top quintile for blood
pressure when body fat levels reached 25 percent.  For
girls, the frequency of high blood pressure increased when
body fat levels reached 30 to 35 percent.  Similar levels of
percent body fat also were associated with the top quintile
for total cholesterol levels.

Etiology

     The etiology of obesity in children is complex. 
Familial and genetic factors are among those associated with
obesity in children.  For example, Mayer (1965) showed that
offspring of two obese parents have an 80-percent chance of
becoming obese, as compared to a 14-percent chance for
offspring of two parents of normal weight.  These data
indicate that obesity is related to familial factors that
are transmitted through heredity, through a shared
environment, or through both.  However, subsequent studies
on twins and adoptees have shown that body fat is
transmitted genetically to a moderate extent (Stunkard et
al., 1986a, 1990; Bouchard et al., 1988; Sorenson et al.,
1989).  Studies have shown that the correlation for measures
of body fat in pairs of relatives increases as the
relationship gets closer.  Furthermore, siblings by adoption
have no significant correlation in body fat whereas related
siblings do.  The correlation increases with dizygotic twins
and is highest for monozygotic twins (Bouchard et al.,
1988).  Bouchard has estimated that about 25 percent of the
variation in body fat is genetic.  Thus, much of the
variation in body fat is due to environmental factors.

     Environmental factors that are expected to play a key
role in body weight are diet and physical activity.  A
significant, direct relationship between energy intake and
body weight has generally not been found in children
(Rolland-Cachera and Bellisle, 1986).  Studies relating
physical activity with body weight are inconsistent
(Sunnegardh et al., 1986).  Furthermore, most studies do not
show that obese children eat more than lean children (Durnin
et al., 1974), and only a small number of studies show that
obese children are less physically active than lean children
(Tell and Vellar, 1988; Bullen et al., 1964).  However,
dietary and physical activity assessment methods are
extremely imprecise, and caloric intake estimates especially
have high intraindividual variation.  Large errors of
measurement and high individual variability make it
difficult to detect significant relationships.

     Hours of television viewing have been linked to the
prevalence of obesity.  Dietz and Gortmaker (1985) found
that, in a national sample of children ages 12 to 17 years,
the prevalence of obesity (defined by the 85th percentile of
TSF measurements) increased 1.9 percent for each hour per
day spent watching television.  Whether the increased
prevalence of obesity is a result of decreased physical
activity or of increased snack intake as a result of
watching television needs to be investigated further.

     Socioeconomic status has been found to be related to
obesity in adults.  However, no overall trend is discernible
in children.  In a review by Sobal and Stunkard (1989),
about one-third of the studies found a positive association,
one-third a negative association, and one-third no
association.

Summary

o    A generally accepted definition of obesity in children
is needed.

o    The measures that define obesity in children need to
take into account the natural history of fat deposition
related to normal growth and development.

o    Obese children have a higher probability of becoming
obese adults, which may set the stage for premature CVD in
adulthood.  Furthermore, pediatric obesity is associated
with cardiovascular risk factors in childhood.

o    Environmental factors are important in obesity in
children because genetics account for only a portion of the
variation in obesity.

o    Longitudinal studies with consistent use of the various
measures would provide a better understanding of the
etiology of obesity in children.


OBESITY IN ADULTS--Diane Bild, M.D., M.P.H.

     An examination of obesity in adults needs to include an
examination of the health risks and demographic factors
associated with obesity, as well as other factors that may
be causally related to obesity.

Prevalence

     Difficulties of definition and measurement continue to
be a problem in describing the epidemiology of obesity in
adults.  The NHANES II data and definition of obesity
nevertheless provide a reference base for comparing studies
and examining trends.  Approximately one-fourth of the
American population is overweight based on the NHANES II
definition (greater than or equal to the sex-specific 85th
percentile of BMI for 20- to 29-year-olds) (National Center
for Health Statistics, 1981).  As figure 7 illustrates,
adult obesity in the United States has been increasing in
both men and women and in both African Americans and whites. 
Of important note is the particularly high prevalence of
obesity in African-American women.


Weight and Mortality

     Data from three large studies--the 1959 Build and Blood
Pressure Study, the 1979 Build Study, and the 1979 American
Cancer Society Study--show an increase in mortality ratios
for both men and women with increasing relative weights
(figure 8).  The J-shaped curve also indicates high
mortality among those 20 percent below average weight.  By
failing to separate smokers from nonsmokers, the Build
Studies overstate the mortality risks of having lower weight
and understate the mortality risks of being overweight
because smokers tend to weigh less and have higher mortality
rates than nonsmokers.  However, 28-year followup data from
the Framingham Heart Study suggest increasing mortality with
increasing weight, even after controlling for smoking
(Higgins et al., 1988).

Weight and Cardiovascular Risk

     The Framingham data demonstrated that higher quintiles
of BMI are associated with increased levels of total
cholesterol, systolic and diastolic blood pressure, glucose,
and uric acid (Higgins et al., 1988).  Furthermore, obesity
was associated with an increased risk of coronary heart
disease (CHD), independent of these risk factors.  The
Nurses Health Study of more than 120,000 registered nurses
ages 30 to 55 found an increased risk of CHD associated with
greater BMI (Manson et al., 1990).  In this study, women
with a BMI greater than or equal to 29 had almost double the
risk of CHD compared to women with a BMI less than 21, after
controlling for hypertension, diabetes, high serum
cholesterol, and parental myocardial infarction.

Weight Change and Cardiovascular Risk

     Five-year data from the Coronary Artery Risk
Development in Young Adults (CARDIA) study of 5,000 men and
women ages 18 to 30 years at baseline (Friedman et al.,
1988) provided insight into the effects of weight loss,
weight maintenance (within 5 pounds), and weight gain on
cardiovascular risk factors.  Those who lost weight (initial
loss of 5 pounds without regain of more than 5 pounds over 5
years) showed decreases in blood pressure, whereas those who
gained showed increases in blood pressure (figure 9). 
Significant changes in HDL-cholesterol levels also were
noted:  Those who lost weight raised their HDL-cholesterol
levels, whereas those who gained lowered their
HDL-cholesterol levels (figure 10).


Weight, Race, and Socioeconomic Status

     According to cross-sectional data from the NHANES II,
the mean weight of both white and African-American men
increased with age until the forties and then reached a
plateau, whereas the mean weight for women increased
throughout adulthood to age 74 (National Center for Health
Statistics, 1981).  Data from the CARDIA study showed that
weight is not related to education level in white men, but
that African-American men who are better educated have
slightly higher BMIs than their less educated counterparts
(Burke et al., 1990).  African-American and white women with
more education or with higher incomes have lower BMIs than
those women with less education or lower incomes.

Etiology

     An examination of the factors influencing obesity in
the CARDIA study revealed no relationship between skinfold
thickness and caloric intake in either men or women
(Slattery et al., 1992).  The absence of an effect could be
due to difficulty in measuring caloric intake and to the
fact that people who weigh more may be less active and
therefore require fewer calories.  Skinfold thickness and
level of physical activity were significantly related in
both men and women and in both African Americans and whites
(Slattery et al., 1992).  BMI also was correlated with
fitness, as measured by duration on a treadmill test (Sidney
et al., 1992).  Again, interpretation of cause and effect is
difficult:  Do those who are more fit weigh less because of
increased energy  expenditure?  Or are those who weigh more
less active and therefore less able to perform well on a
fitness test?

     Attitudes and diet practices may play a role.  In the
CARDIA study, African-American women reported that they
dieted, considered obesity harmful, and perceived themselves
to be fat less often than did white women, despite the
higher prevalence of obesity in African-American women
(figure 11).  Parity is also associated with BMI.  Women who
have more children and women who give birth at an earlier
age tend to have higher BMIs (Burke et al., 1992).

     Genetic predisposition to obesity is an important
factor.  CARDIA data showed a definite relationship between
parental obesity and skinfold thickness in offspring ages 18
to 30 years, with the relationship particularly strong when
both parents are obese (Burke et al., 1991).  A Danish study
that compared adopted children to both their biological
parents and adoptive parents also showed a strong
correlation between children's BMIs and their biological
parents' BMIs but not their adoptive parents' BMIs (Stunkard
et al., 1986b). 

Priorities

     With many overweight individuals (46 percent of
overweight men and 61 percent of overweight women) trying to
lose weight and billions of dollars being spent annually on
weight loss efforts, increased attention to the prevention
of obesity is needed.  An equally great challenge is
determining what recommendations should be given to already
obese individuals.


GENERAL DISCUSSION

     Dr. JoAnn Manson stated that the benefits of long-term
weight loss cannot yet be fully addressed because not enough
individuals have sustained long-term weight loss.  The
evidence is clear, however, that weight loss has such
cardiovascular benefits as lowering blood pressure and
improving both lipid profiles and glucose tolerance. 
Furthermore, no clear evidence suggests adverse
physiological effects from weight loss.

     The panel members were asked whether they knew of any
race differences in the physiological effects of obesity,
considering there are race differences in the perceptions of
obesity.  Dr. Manson was aware of possible differences with
diabetes.  After adjusting for BMI, African-American
women--and perhaps African-American men--may be at greater
risk than whites for developing glucose intolerance and
diabetes.  The panelists were unsure whether there were
greater risks of obesity for other end points.  The greater
prevalence of hypertension in African-American women as
compared with white women is explained chiefly by the
greater prevalence of obesity in that population.

     Dr. David F. Williamson, Centers for Disease Control
and Prevention, shared a recent article, "Childhood weight
and growth rate as predictors of adult mortality" by Nieto
and colleagues (1992), published in the American Journal of
Epidemiology.  The study showed that even in young children
long-term health outcomes are adversely affected by obesity.

     Dr. Williamson also commented that examining
longitudinal data, as opposed to cross-sectional data, is a
better way to look at weight gain over time.  Based on
NHANES I followup data, both men and women gain weight, at a
decreasing rate, up to their mid-fifties, and women gain
more weight than men.  After that, with increasing age, they
both lose weight, but women lose more weight than men.  

     Dr. Cheryl Ritenbaugh, University of Arizona, asked
whether there are any data on cardiovascular risk in
physically active individuals who weigh more.  Dr. Manson
cited the Nurses Health Study, which showed a strong
independent effect of BMI and increasing CHD, after
controlling for physical activity.  Several epidemiological
studies suggest that weight loss, whether by caloric
restriction or physical activity, produces comparable
effects on cardiovascular risk factors.  Dr. Ritenbaugh
responded that, from the standpoint of public health and
prevention, consideration of what could be achieved by
increasing levels of fitness without initial attention to
weight loss was needed.

     Dr. Robert W. Jeffery, University of Minnesota, asked
whether the CARDIA investigators have looked prospectively
at the relationship of reported dieting to weight gain or
loss, or at the relationship of dieting to cardiovascular
risk factors, after controlling for body weight.  Dr.
Millicent Higgins, NHLBI, stated that the prevalence of
dieting was related to the change in body weight; however,
only a very small number of individuals had actually
sustained weight loss.  Much of these data have not yet been
analyzed fully.

     Dr. Barbara C. Hansen, North American Association for
the Study of Obesity, suggested that the intervention focus
on primary prevention rather than on the promotion of weight
loss, in light of the historical data on groups of people
who have been calorically restricted (but not necessarily
nutritionally deprived) and the studies that have been
conducted in rodents.  Dr. Manson agreed that the emphasis
should be on primary prevention, not only because secondary
prevention (reversing obesity) has such a dismal track
record but also because of the questions that have been
raised about the adverse health effects caused by weight
loss and weight cycling.  However, attention still must be
given to the one-quarter to one-third of Americans who are
already obese.

     Dr. Peter Wood, Stanford University, asked about the
relationship between obesity and cardiovascular morbidity
and mortality in people age 65 and older.  Dr. Manson
responded with Framingham data, which showed similar
findings on cardiovascular morbidity and mortality and BMI
in this age group.  There is evidence that lower weight
produces better cardiovascular risk profiles in the older
population.  The only disease risk that has been found to be
associated with leanness in women is osteoporosis and
related fractures.  In men, no disease appears to be
adversely influenced by leanness.

     William Fabrey, National Association To Advance Fat
Acceptance, mentioned some research that showed that
African-American men may suffer from higher rates of CVD
that are attributable to oppression and asked whether any
research has been conducted on the effects of high levels of
stress and obesity.  Dr. Bild stated that this was an area
for further study but noted the difficulty in measuring
psychosocial stress.

     Dr. Millicent Higgins, NHLBI, expanded upon the
discussion of how leanness influences mortality.  She
mentioned that, in addition to osteoporosis, chronic
obstructive lung disease and lung cancer are related to
leanness, but it is likely that this association is due to
the higher prevalence of smoking among the lean. 
Identifying the reasons for the weight loss, voluntary or
involuntary, in many of the studies is difficult.  The
underlying disease process is most important, especially in
older Americans.

     Nancy Summer, Council on Size and Weight
Discrimination, requested clarification of a statement from
the Technology Assessment Conference on Methods for
Voluntary Weight Loss and Control that indicated that a
10-percent reduction in weight had positive effects on
health. Dr. Manson responded that weight loss can often
improve insulin sensitivity and glucose tolerance.  In very
obese individuals, glucose intolerance also is influenced
positively by small reductions in body weight, but the
condition is not necessarily normalized.

     Robert Garrison, NHLBI, made a final comment on the
issue of obesity and the older population.  He referred to a
1988 paper by Harris and colleagues (1988) on the Framingham
Heart Study, published in the Journal of the American
Medical Association, which showed a powerful positive
relationship between weight and mortality in individuals
over age 65, even after controlling for confounders (such as
cigarette smoking).


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PANEL 2:  STRATEGIES FOR OBESITY PREVENTION

     The panel on strategies for obesity prevention explored
current school-, family-, and community-based strategies for
preventing obesity and suggested directions for future
research and activities.  Dr. Patricia J. Elmer, University
of Minnesota, chair of the panel, introduced the topic.  Dr.
James F. Sallis, Jr., San Diego State University, examined
what is known about the results of school-based obesity
prevention programs and discussed related research issues
and priorities for school activities.  Dr. Leonard H.
Epstein, University of Pittsburgh, focused on
epidemiological studies of family-based obesity programs and
emphasized the importance of family involvement as well as
exercise in long-term weight control.  Dr. Robert W.
Jeffery, University of Minnesota, described results from
four community-based obesity programs and stressed the
relationship of public health and the prevalence of obesity
in the community.  The panel concluded with general
discussion and comments by participants.


INTRODUCTION--Patricia J. Elmer, Ph.D., R.D.

     Obesity is a problem with many dimensions and leads to
difficult questions such as how people with obesity can best
be reached and how the development of obesity can best be
prevented.  School- and clinic-based programs as well as
populationwide interventions are needed, and program
effectiveness needs to be analyzed.  Different approaches to
intervention are offered in school-based programs,
family-based programs, and community-based programs.  What
are the advantages and disadvantages of these approaches?

     Variables that have been used to identify key
interventions include age and gender as well as ethnicity
and geographic location.  Additional insights into effective
strategies for intervention may be provided in the
differences between weight cycling and smoking cycling. 
Evidence suggests that individuals who quit smoking a number
of times are more successful in ultimately stopping
permanently; however, this is not true for individuals who
lose weight a number of times.  The reasons for this--that
is, the behavioral and psychological components of weight
cycling--need to be investigated.


SCHOOL-BASED OBESITY PROGRAMS--James F. Sallis, Jr., Ph.D.

     A large number of children can be reached in
school-based obesity programs, especially younger children. 
Comprehensive treatment and prevention programs can be
conducted on a daily basis for many years, and relevant
professionals are usually available to help monitor the
programs.  School-based obesity programs offer multiple
opportunities, most commonly for educational and behavioral
modification interventions, through the physical education
curriculum, the school lunch program, environmental changes,
and summer school programs.  Comprehensive school-based
obesity programs also may include health education services
for peer groups, families, and school staff.  School-based
programs are, however, only one component of the overall
health promotion model, and they are limited in the services
they can provide.

Treatment Programs

     Ward and Bar-Or (1986) and Parcel and associates (1988)
reviewed 10 studies of school-based obesity treatment
programs.  Elementary and secondary school students who were
overweight were selected for participation in the programs. 
In general, treatment consisted mostly of educational
components (covering diet, physical activity, and behavior
modification), but other components involved modified
physical activities and school lunches.  Mean treatment
length was 15 weeks.  Treatment programs, reported in
changes in percentage of overweight participants, were more
successful in elementary school children (a 12-percent
reduction) than in secondary school students (a 5-percent
reduction).  However, which components were related to the
success of the programs, and why the younger children were
more successful than the older children, could not be
determined.  The length of treatment was not related to
outcome.  In addition, most treatment studies included only
a few key components (diet and physical activity education),
made no provisions for modifying the environment, had little
parental involvement, and demonstrated no long-term effects. 
 

Prevention Programs  

     Obesity was one of the risk factors tracked in seven
studies of school-based cardiovascular risk reduction
programs (see table 1).  Interventions in these programs
lasted from 7 weeks to 5 years and included 4,000 primary
school students (in three programs) and 3,400 secondary
school students (in four programs).  Intervention components
included modified physical education classes as well as
education about diet and about physical activity.  Only one
primary school included in the studies modified its school
lunches; three secondary schools involved parents.

     Table 1 shows the effects of school-based prevention
programs.  Of the seven programs, one in the primary grades
(a physical education intervention) and two in the secondary
grades had a significant effect on obesity.  The table also
illustrates that risk factors other than obesity (for
example, blood pressure, lipids, smoking) tended to be
influenced more significantly in all programs.  However,
none of the programs made much effort to combine education
and environmental change.  Most did not include either
physical education and school lunch modification or involve
parents, and they also did not emphasize behavioral skill
training.  Thus, they did not demonstrate the potential
effectiveness of prevention programs for obesity that
include most or all of the key components.

     Future studies of prevention need to address the
implications of the modest changes in body fat in youth that
these seven studies revealed as well as the effects of
schoolwide prevention programs on obese youth.  Because the
number of school-based treatment programs appear to be
decreasing while prevention programs are increasing, it may
be time to put more emphasis on treatment programs.  The
best direction for intervention programs to take may be that
demonstrated by the ongoing NHLBI Child and Adolescent Trial
for Cardiovascular Health Study.  This trial includes
educational and environmental components in addition to
family involvement and may indicate the effects of a
prevention approach on the development of obesity.

Key Research Issues

     Among key issues in researching school-based obesity
programs are the selection, recruitment, and retention of
the population targeted for treatment; the long-term effects
of treatment; the feasibility and effectiveness of program
components; and the quality of implementation of the
interventions.  Other research issues that must be
considered are the optimal timing and duration of the
intervention, the effectiveness of integrating simultaneous
treatment and prevention programs, monitoring the
effectiveness of diet and physical activity, and appropriate
interventions for ethnic groups.  Important related issues
are how to implement obesity prevention and treatment
programs in the schools (particularly given the already
limited resources) and how to determine the most effective
settings (schools versus clinics) for these programs.  In
addition, explorations of the limits of intervention
effectiveness need to be made because no program to date has
included all the components required to ensure quality
implementation.  One of the most promising features of
schools as intervention settings is the possibility of
long-term programs, and the cumulative effects of both
treatment and prevention strategies over several years need
to be examined.

Priorities

     The number one priority for school-based programs
should be modifying the composition of school lunches and
ensuring the active participation of students in physical
education classes.  Modifications to these existing programs
are definitely needed to make them more effective for
obesity prevention and treatment.  Behavior modification
components need to be built into programs related to diet
and physical activity.  Other priorities include conducting
parent education and establishing treatment programs for
obese children.  In furthering priorities, the psychosocial
effects of treatment need to be considered to ensure that
psychosocial functioning is enhanced and that no child is
stigmatized.


FAMILY-BASED OBESITY PROGRAMS--Leonard H. Epstein, Ph.D.

     Data from recent studies emphasize the importance of
family-based obesity programs (Epstein and Wing, 1987). 
Results of epidemiological studies suggest that children of
obese parents have a greater risk of developing obesity in
adulthood than children with lean parents (Charney et al.,
1976; Garn and LaVelle, 1985).  Thus, family-based obesity
programs that expect both generations and all family members
to participate actively and make behavior changes can have
more of an impact.  Family-related variables--that is,
factors common to multiple family members such as food
storage, family environment, and behavior support--can be
capitalized on and manipulated to produce family behavior
changes.

     Among the studies demonstrating the need for
family-based obesity programs are four epidemiological
studies (Abraham and Nordsieck, 1960; Abraham et al., 1971;
Stark et al., 1981; Garn and LaVelle, 1985) that showed that
obese older children are more likely to retain obesity in
adulthood and that the relative risk is particularly high
for children ages 10 to 12 (see table 2).  These data
suggest that, as children become older, they have a greater
relative risk for becoming obese adults and provide a good
indication of the ages when interventions are needed.


     Table 2.  Relative Risk by Age of Obese Children Who
Become Obese Adults

                    Percent who become
Age of obese child  obese adults        Relative risk

0-6 months              14                   2.3
0.5-5.5 years           20                   3.4
7 years                 41                   3.7
10-12 years             70                   6.0


     In a 10-state nutrition study, Garn and Clark (1976)
analyzed the triceps skinfold measures of boys and girls as
a function of parental weight.  Children of two obese
parents were found to have much more body fat than children
of two lean parents, and an interaction between parents and
children was demonstrated:  that is, an obese child with
obese parents has a different risk than an obese child with
lean parents.

      In another study, Charney and colleagues (1976)
followed children with heavy or thin parents from age 6
months to adulthood.  Results again suggested an interaction
between parent and child and that treating obese children
with obese parents was more important than treating obese
children with lean parents.  The percentage of children who
became obese adults as a function of parental weight is
shown in table 3.


Table 3.  Percentage of Children Who Become Obese Adults as
a Function of Parental Weight

                    Percent with   Percent with
                    heavy parents  thin parents

Heavy children who
become obese adults    51                20

Thin children who
become obese adults    15                11



Four 10-Year Followup Epidemiological Studies

     The four recent family-based 10-year treatment studies,
one of which has been published (Epstein et al., 1990),
involved children ages 6 to 12 years who were 20- percent
overweight, in the 85th percentile of triceps skinfold, and
had no psychiatric disorders.  The children apparently had
no reading disabilities (they had to keep food records). 
All had obese parents, except for the ones in whom the
long-term
effects of parental weight on child weight loss were
being studied (Epstein et al., 1987).  Treatments were once
a week for 8 weeks and then once a month for 4 months. 
After 10 years of followup, the data showed that a
significant number of children in the treatment programs
maintained treatment effects, as compared to those children
not in the treatment programs.  As discussed below, these
studies demonstrated the importance of active participation
by all family members and of targeting family-related
variables.

o    Study 1 (Epstein et al., 1990):  Targeting children
versus targeting children and parents--This study compared
results when the child alone was targeted for treatment
versus when both the child and parent were targeted.  A
nonspecific control group (in which no particular family
member was targeted) also was included.  The study used the
Cooper lifestyle exercise program and focused on habit and
weight change behaviors.  The results suggest that involving
the parent as an active participant has a large effect on
long-term change.

o    Study 2 (Epstein et al., 1984):  Diet versus diet and
lifestyle--This study examined differences between
emphasizing diet versus emphasizing diet and lifestyle
modifications, including exercise.  Parents were not
included as active participants.  This study showed no
significant differences between the two interventions at the
10-year point.

o    Study 3 (Epstein et al., 1987):  Positive versus
negative family history--This study compared the effects of
a positive family history (at least one heavy parent) with
the effects of a negative family history (no heavy parents). 
Obese children performed more poorly with treatment when one
parent was obese than when both parents were lean, even when
the treatment was the same.  Differences were noted at 1
year and maintained for 10 years.

o    Study 4 (Epstein et al., 1985):  Lifestyle versus
aerobic exercise--This study targeted both children and
parents and compared the effects of a lifestyle exercise
program (walking during daily activities), the effects of a
more traditional aerobic exercise plan (a 2-mile run), and
the effects of no exercise.  The 10-year data showed
long-term weight maintenance effects for both groups that
exercised as compared to the group that did not exercise.

Personalized System of Instruction Study

     A recent followup study of the treatment studies
described above (Epstein et al., submitted [a]) was based on
a competency-based education system called the Personalized
System of Instruction (PSI).  With the PSI, children learn
at their own pace and must master basic skills before moving
on to more complex skills.  The study involved 6 months of
weekly treatment and 6 months of maintenance meetings.  A
treatment effect (measured in percent over BMI change)
appeared at 12 months in children and their parents but was
not sustained at 2 years.  This suggests that more
personalized instruction is needed during the weight
maintenance phase of the treatment program.

Obesity and Television Watching Studies

     Research has investigated the correlation between
prevalence of obesity and the number of hours spent watching
television (Dietz and Gortmaker, 1985).  Epstein and
associates recently looked at whether decreasing sedentary
activities--that is, cutting back on television viewing--had
a positive effect on weight.  Three treatment groups were
included:  diet plus increased exercise, diet plus decreased
sedentary activity, and diet plus a combination of increased
exercise and decreased sedentary activity.  Reductions in
primary sedentary behaviors (watching television) were
reinforced to determine if decreasing the sedentary behavior
would result in increased activity or in another sedentary
behavior (such as reading a book).  Treatment involved 4
months of weekly meetings and 2 months of maintenance.  The
diet plus decreased sedentary activity treatment showed the
most powerful effect on percent overweight change--at both 6
months and 1 year (Epstein et al., submitted for publication
[b]).  The data suggest that children who received positive
reinforcement in cutting back on sedentary behaviors and who
were given a choice of behaviors were more likely to select
and prefer active behaviors.  The researchers suggest that
children who are not given a choice of activities will
eventually select more active behaviors but not necessarily
enjoy them.

Recommendations for Family-Based Obesity Programs

o    Parents must have an active role in the treatment
program.

o    Exercise is the key to long-term weight control in all
obesity programs.

o    The family's environment and behaviors must be
targeted.

o    Specialized training in childhood behavior modification
needs to be provided when treating the entire family.

o    Obesity treatment programs with dietary changes do not
affect a child's growth.  The 10-year followup studies
demonstrated that children who participated in treatment
programs were within 2 centimeters of the height of their
same-sex parent.

o    Programs need to emphasize that preventing obesity also
may prevent eating disorders and reduce cardiovascular risk
factors.

o    Further study of the psychosocial effects of obesity
treatment programs in children is needed.


COMMUNITY-BASED OBESITY PROGRAMS--Robert W. Jeffery, Ph.D.

     Obesity is primarily an adult-onset disorder.  It is
several times more common in middle-aged adults than in
young adults, and by age 50, nearly half of all adults are
20 percent or more above desirable weight.  Susceptibility
to obesity is widespread; particularly at risk are
minorities (especially African-American women) and young
adults of lower socioeconomic status.

     Obesity must be viewed as a community problem and
intervention programs targeted appropriately.  To affect
public health, influencing the prevalence of obesity in the
community is essential.  To be successful, community
intervention programs must: 

o    reach a large number of young adults, particularly
those at highest risk;

o    change eating and exercise habits that are related to
obesity; and

o    be available at a reasonable cost.
     Progress in developing community-based programs is
illustrated in four community intervention projects
conducted by the University of Minnesota.  

Healthy Worker Project

     The first of these programs, the 1987-90 Healthy Worker
Project (HWP), involved worksite health promotion (Jeffery
et al., 1993).  In this trial, 32 public and private
worksites with a wide range of occupations were randomly
assigned to a treatment group or a control group.  The 16
worksites in the treatment group received free health
promotion programs on weight control and smoking cessation. 
Onsite educational classes were offered four times over a
2-year period.  A payroll incentive plan was used in which
modest amounts of money were deducted from paychecks and
returned contingent upon progress made toward the weight
loss goal.  About 20 percent of all employees participated
in these classes (38 percent of overweight employees and 10
percent of normal-weight employees).  Both weight loss and
weight gain prevention were encouraged as a personal goal. 
The mean weight loss for HWP participants in weight loss
classes averaged about 5 pounds over 6 months.  The overall
effect of the intervention on all employees was measured by
changes in BMI.  Average weight changes were small, and
there were no differences between the 16 worksites in the
treatment group and the 16 worksites in the control group.

Invest in Your Health Study

     The second community intervention program was a weight
loss and smoking cessation effort utilizing a direct mail
and home correspondence strategy called Invest in Your
Health (IYH) (Jeffery et al., 1990).  Participants were
recruited by mail and offered one of two programs:  a $5
fee-for-service program consisting of a self-help manual and
monthly newsletters or a program identical in content but
incorporating a $60 incentive deposit that was fully
refundable contingent upon reaching a weight loss goal. 
Weight loss goals were selected by the participants
themselves, and weight gain prevention was encouraged as a
program option.  Evaluation was made through self-reported
weights and heights using a return postcard.  These reports
were validated by actual measurement at baseline and 1-year
followup in a subset of the sample.  Responses were obtained
from about 6 percent of households in the $5 fee-for-service
program and from 1 percent in the program incorporating the
$60 incentive deposit.

     Individuals participating in both programs lost modest
amounts of weight, with men losing more weight than women. 
Individuals participating in the incentive-deposit program
lost twice as much weight as those participating in the
fee-for-service program, but only one-fifth as many
participated.  Thus, the overall community impact should be
larger with the fee-for-service program.  IYH demonstrated
that a correspondence program not only can reach a large
number of people at a reasonable cost but also can produce
modest weight losses of a magnitude useful for
populationwide obesity prevention efforts.

Pound of Prevention Trial

     The Pound of Prevention (POP) trial was a
correspondence course that focused on studying weight gain
prevention rather than weight loss (Forster et al., 1988). 
The participants--219 normal-weight volunteers--were
recruited by mail and randomly assigned to a treatment
program for preventing weight gain or to a control group. 
The volunteers were more likely to be women and nonsmokers. 
The POP trial utilized monthly newsletters, a minicourse on
weight control, and a deposit incentive system ($10 per
month returned if no weight was gained).  The POP trial also
collaborated with a local health department to enhance
generalizability to a community setting.  The overall
recruitment response rate was 13 percent.  

     Over 12 months, the treatment program group lost an
average of 1 kilogram, but there was no weight change for
the control group.  In the treatment group, 82 percent did
not gain weight compared to 56 percent in the control group. 
The differences were statistically significant. 
Characteristics of treatment group participants that
correlated with weight loss were male gender, older age,
nonsmoking, no prior experience in weight control, and
higher participation in the program activities.  The POP
trial demonstrated that weight gain prevention programs can
be implemented successfully in communities at relatively low
cost.

Minnesota Heart Health Program

     The Minnesota Heart Health Program (MHHP), a 10-year
project, was designed to evaluate the effectiveness of
multicomponent interventions in reducing cardiovascular
disease incidence and mortality (Leupker et al., submitted). 
Three matched community pairs (approximately 500,000 total
individuals) participated.  Interventions over 7 years
included risk factor screening, use of mass media and adult
education, and activities at worksites, schools, and
restaurants.  Goals of the program included cholesterol
reduction, smoking cessation, blood pressure reduction,
increased physical activity, and weight control.  MHHP
results showed dramatic weight gains (as measured by BMI)
throughout the program in all communities, both before and
after the educational activities were in place.  The MHHP
thus had no communitywide impact on obesity.

Conclusions

     Community-based programs can indeed reach large numbers
of adults and interest them in weight gain prevention
programs.  Short-term effects on weight are small but
positive.  However, the effectiveness of community-based
programs in reducing the prevalence of obesity in whole
communities has not yet been demonstrated.  Additional
research in this area is needed to examine better
recruitment efforts that can attract the large numbers of
participants required to demonstrate a communitywide effect. 
None of the community-based programs described here have
demonstrated a true community effect.  Additional studies of
long-term effects are also needed.


GENERAL DISCUSSION

     Dr. Eva Obarzanek, NHLBI Division of Epidemiology and
Clinical Applications, asked whether environmental changes
similar to those in schools for children have been
implemented for adults.  Dr. Jeffery suggested that such
changes could be made via food labeling and marketing
practices and that consumption of high-fat foods could be
discouraged by adding an excise tax to foods based on their
fat content and by regulating portion-size packaging.  He
argued that food manufacturers should not have unlimited
marketing access to the public and that it is essential to
educate the public so that people realize that the food
supply is not entirely benign.

     In response to a question about any characteristics of
parents or household environments that improved study
outcomes, Dr. Epstein stated that, over the short term,
there is a very high correlation between parent weight
changes and child weight changes.  However, over 5 to 10
years, parents generally go back to their original weight,
even while the child maintains the weight change.  After 10
years, there are no longer any treatment effects for
parents.  Modeling does not appear to be in effect because
the child does not model the parent's weight gain. 
Promising areas for research are the influence of parental
support on a young child's developing eating habits, the
influence of roommate support for exercise on young adults,
the influence and number of televisions in the household,
and food-storing practices in the household.

     In response to a followup question concerning other
parent or household characteristics affecting study outcomes
(e.g., socioeconomic status and single parenthood), Dr.
Epstein said that studies have not shown socioeconomic
status to predict weight loss.  Other characteristics that
have an effect are the size of the family (children from
large families do not do as well, particularly if older
siblings are overweight) and the age of the child (older
children ages 11 to 12 years do better than younger children
ages 9 to 10 years).

     Dr. Elmer commented on the roles of physical activity
and cultural norms in weight loss.  In her studies, 25
percent of adults at baseline reported doing no leisure
physical activity.  Those able to increase their physical
activity the most were already active.  Those who maintained
their weight, or who lost the most weight, maintained the
most change in their leisure physical activity, and this
maintenance was related to a valuing of and a preference for
physical activity that had been established at an early age. 
Thus, how the cultural norms relating to physical activity
can be influenced most effectively is an obvious concern in
establishing any weight loss program.

     Dr. JoAnn Manson, Brigham and Women's Hospital and
Harvard Medical School, noted that one of the limitations of
worksite programs is that they do not reach unemployed women
who are at greatest risk of weight gain.  She asked whether
any of the community-based programs had compared efficacy in
preventing weight gain among women employed outside the home
versus among women at home and, furthermore, whether there
were any interventions targeting women at home.  Dr. Jeffery
replied that he knew of no interventions targeted to this
group but that it is an area for future research.

     Dr. Elaine Stone, NHLBI, asked Dr. Epstein whether the
issue of depression in children and parents had been
studied.  Dr. Epstein replied that the data are being
reviewed and that the first 10-year followup showed a few
children with psychological disorders, but that there was no
untreated control group to use for comparison.  However, the
data that have been collected seem to show no greater
prevalence of these conditions in obese children than in the
general population.

     Dr. Stone commented on a school-based study conducted
in North Carolina, in which a nurse-delivered American Heart
Association program was implemented.  The program first used
the classroom curriculum approach and then a high-risk
individualized approach for obese children.  The nurse
delivering the program dropped the high-risk approach,
however, after noting that the children might be stigmatized
because they were being separated out of the classroom.

     Dr. William Dietz, American Academy of Pediatrics,
suggested that school lunch and television behaviors could
be potentially valuable arenas for long-term interventions. 
Both overlap with other behaviors--school lunch with
cholesterol and cancer prevention efforts, and television
with prevention efforts aimed at alcohol consumption,
violence, and aggression.  Both are free of stigmatization
because the focus is not on obesity.

     Dr. Dietz asked the panel whether they saw any
indications that programs such as theirs have an adverse
impact on those who were not successful.  Dr. Epstein
responded that the literature suggested that obese children
develop internal problems (depression) versus external
problems (aggression, violence, substance abuse); however,
this literature is vague and confusing.  His studies show
that depression in obese children was linked to parental
depression rather than to obesity.  Dr. Sallis responded
that he had not found any study that examined the
psychosocial effects of school-based programs and that a few
correlation studies showed a poorer self-image in obese
children, but that depression or more serious symptoms were
not seen.  The issue of stigmatization was not addressed in
the studies he had reviewed, but this could be due to the
fact that some of these studies were conducted after school.

     William Fabrey, National Association To Advance Fat
Acceptance, commented that treatment for children should not
be stigmatizing and that sensitivity training is needed for
individuals working with obese children.  He added that
payroll-based programs, as described by Dr. Jeffery, should
be avoided because such programs may be a violation of human
rights.  Even if these programs are voluntary, too often
participation is not really as voluntary as it may seem.

     Karen VanLandegham, National School Health Education
Coalition, Inc., commented to Dr. Sallis that because
school-based prevention programs should encompass
kindergarten through 12th grade, be ongoing, and be
incorporated into other health education programs, political
issues were involved in efforts to implement the programs. 
Dr. Sallis acknowledged the limitations in school budgets
and their effects on starting new programs and gave an
example of a school system with this situation. 
Demonstration of the effectiveness of these programs remains
critical due to the various constraints on their
implementation.


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PANEL 3:  ISSUES IN EDUCATING THE PUBLIC ABOUT WEIGHT AND
OBESITY

     The third panel examined issues in educating the public
about weight and obesity.  Dr. Cheryl Ritenbaugh, University
of Arizona, chair of the panel, introduced the topic,
emphasizing factors and issues that affect the needed
emphasis on exercise.  Dr. Pauline Powers, University of
South Florida, discussed nutrition in adolescents.  Dr.
Bonnie Spring, Chicago Medical School and Veterans Affairs
Medical Center, described the relationship of smoking and
weight gain.  Dr. Arthur S. Leon, University of Minnesota,
explored the role of physical activity in the prevention and
management of obesity.  Dr. Jeffery Sobal, Cornell
University, reviewed the sociocultural and demographic
issues of obesity.  The panel concluded with general
discussion and comments by attendees.


INTRODUCTION--Cheryl Ritenbaugh, Ph.D., M.P.H.

     Cultural factors influence knowledge, attitudes, and
behavior regarding food consumption and activity patterns
and thus influence body shape and fatness.  One way to gain
perspective on cultural influences is to examine our
language.  "Hunger" expresses our desire to eat;
"supermarket" indicates a place where we can find items for
food intake.  But our language has no analogous word for our
desire to exercise and a place where we can find whatever we
need for exercise.  For example, there are no words to
complete the analogies "Hunger is to eating as ______ is to
exercising," and "Supermarket is to food intake as ______ is
to exercise."

     Our lack of language related to exercise, this cultural
deficiency, has an effect on the first of four factors that
affect obesity.

o    Exercise availability
     --  safety
     --  resources/location
     --  time

o    Food availability
     --  time for preparation
     --  knowledge
     --  income
     --  resources
     --  physical availability
     --  advertising and marketing of food

o    Knowledge and valuation of healthy lifestyles 

     --  education
     --  experience
     --  socioeconomic status

o    Physiology 

     --  energy balance
     --  adipose tissue

     Our culture currently places the greatest emphasis on
the food intake side of the energy balance equation, with
much more limited importance given to exercise.  An
evaluation of this cultural emphasis helps to make clear why
no individual should be blamed when he or she has the
knowledge to lose weight but does not act upon the
knowledge.  The cultural factors of language and what is
emphasized must be considered in educating the public about
weight and obesity.


NUTRITION IN ADOLESCENCE:  OBESITY AND THE HAZARDS OF
TREATMENT--Pauline Powers, M.D.

     Adolescent eating behaviors are of great importance
when considering educational messages to teenagers about
body and weight.  Adolescence is a time of growth; yet,
paradoxically, widespread dieting occurs in this age group. 
Some data suggest that approximately 15 to 22 percent of
adolescents are classified as obese (Laurier et al., 1992;
Gortmacher et al., 1987), but 60 to 70 percent of teenage
girls and 40 percent of teenage boys have dieted either to
lose weight or to maintain weight (Hueneman et al., 1966;
Dwyer et al., 1967; National Institutes of Health, 1992). 
Dissatisfaction with size and shape is very high among
adolescent girls; Moore (1988) reported that 67 percent of
adolescent girls and young women were dissatisfied with
their weight.  Moses et al. (1989) found that fear of
obesity was common among girls irrespective of weight:  51
percent of the underweight adolescent girls they studied
described themselves as extremely fearful of being
overweight, and 36 percent were preoccupied with body fat. 
Weight consciousness occurs even in young children.  Maloney
et al. (1989) found that 45 percent of children in grades 3
to 6 want to be thinner.

     Obesity is defined as an excess of body fat, using a
variety of standards.  Most commonly, obesity has been
defined using anthropometric measurements of height and
weight.  The common standards are the 1983 Metropolitan
height-weight tables for adults or the results of the
National Health Examination Survey (NHES) for children and
adolescents.  The Metropolitan height-weight tables list
desirable weight ranges for height using three different
frame sizes.  Overweight has been defined as 10 percent
above desirable weight and obesity defined as 20 percent
above desirable weight.  The NHES tables define the 50th
percentile as the desirable weight, and obesity is defined
as a certain percentage (typically 20 percent) above the
desirable weight.

     Various body mass indices also have been used including
the currently popular body mass index (BMI).  The National
Center for Health Statistics (NCHS) defines overweight as
the sex-specific 85th percentile of body mass index in men
and women ages 20 to 29 years.  These measures of overweight
are indices of obesity as none of them are based on measures
of body fat.

     Underwater weighing (hydrostatic weighing) is the
classic standard for determining lean body mass and fat
content, but measurements of total body water, total body
potassium, and dual energy x-ray absorptiometry are
techniques that have certain advantages (Powers, 1994d). 
The classic study differentiating overweight and overfat was
written by Welhelm and Behnke (1942) in which they studied
football players:  the athletes were overweight according to
height-weight tables but were actually underfat using
underwater weighing.  Abraham and colleagues (1982) examined
a group of ballet dancers who were normal weight using the
Metropolitan height-weight tables but exhibited high muscle
content, low fat content, and amenorrhea.

     Hoerr and colleagues (1992) illustrated the problems
with the NHES tables used for childhood and adolescent
weight (table 1).  Two groups of adolescent girls (10
African-American females and 16 white females) classified as
obese were studied using underwater weighing, the NHES
tables, and the Slaughter equation (Slaughter et al., 1988). 
Using the standard of underwater weighing, these girls were
an average of only 15.1 percent above desirable fat content;
however, using the NHES tables, they were classified as an
average of 37.7 percent above desirable weight.  In this
study, BMI also incorrectly classified these teenage girls
as more obese than did the underwater weighing technique or
the skinfold technique using the Slaughter equation.

     Other studies show BMI to be problematic even in
patients who are in the normal weight range.  Boyd (1992)
studied normal-weight adolescents with bulimia and anorexia
nervosa, using skinfold measurements (four-site method
described by Durnin and Womersley, 1974), BMI, and
physiological assessment.  Normal BMI did not necessarily
mean that body composition was normal.  For example, an
18-year-old female 5' 4-1/2" in height weighing 120 pounds
had a BMI of 20.1 (i.e., weight was in the desirable range
using the Metropolitan height-weight tables and BMI was in
the desirable range); however, this patient with chronic
anorexia nervosa had multiple signs, symptoms, and
laboratory findings indicating semistarvation including
depletion of total body potassium (using a whole body
counter), cerebral atrophy, and osteopenia.

     More accurate measurements of fat content are available
than BMI, including underwater weighing and dual energy
x-ray absorptiometry (DEXA), but these methods are more
difficult to implement or have radiation risks (Lukaski,
1987).  Skinfold measures (e.g., triceps, biceps,
subscapular, suprailiac) and age-appropriate nomograms
(e.g., those designed by Durnin and Womersley, 1974) may be
reasonable alternatives.

     The average fat content is 18 to 20 percent for young
adult males and 25 to 30 percent for young adult females
(American Alliance for Health, Physical Education,
Recreation, and Dance, 1984; Slaughter et al., 1988). 
Frisch and Revelle (1969) noted that average fat content at
menarche was 24 percent.  Frisch and McArthur (1974)
proposed a fat-content theory of menses and fertility and
provided evidence that the minimum amount of body fat
necessary for menarche is 17 percent and for fertility 22
percent.  Frisch also has posited that both relative and
absolute fat content are important in maintenance of normal
reproductive cycles (Frisch 1988; Frisch 1990).  In their
study of patients with anorexia nervosa who had regained
menses, Meyer and colleagues (1986) provided tentative
support for the theory that 17-percent fat content is
required for menses.

     Although fat content increases with age, usually in the
visceral compartment, very little is known about the
expected and safe fat content with increasing age.  For
adolescents, if fat content is maintained into adulthood,
fat content of 25 percent for adolescent boys and 30 percent
for adolescent girls may be the baseline above which
complications (such as elevated blood pressure and
hyperinsulinemia) are likely to occur (Williams et al.,
1992; Lew et al., 1979).  This fat content probably
corresponds to greater than 120 to 130 percent of the
desirable weights using the Metropolitan height-weight
tables or the NHES tables.

Risks of Adolescent Obesity

     Adolescent obesity is associated with both
physiological and psychological risks.  Physiological risks
have been well documented (Lauer et al., 1975; Aristimuno et
al., 1984; Becque et al., 1988) and include:

     o    increased blood pressure;

     o    increased total cholesterol and abnormal
lipoprotein ratios; and

     o    hyperinsulinemia.

     Psychological risks include:

     o    poor body image, which is "imprinted" in
adolescence (Stunkard and Burt, 1967);

     o    low self-esteem, including fear of obesity and
increasing preoccupation with size and shape (Maloney et
al., 1989); and

     o    cultural stigmatization.  Children and adults
devalue overweight children even more than children with
other disabilities (Richardson et al., 1961; Harrison and
Smith, 1982; Maddox et al., 1968).

     Certain physiological and psychological factors may
predispose obese adolescents to adult obesity, and their
risk of becoming obese is high.  However, not all obese
adolescents become obese adults.  Abraham and Nordsieck
(1960) reevaluated 120 10- to 13-year-olds in adulthood and
found that 86 percent of overweight boys were overweight
adults compared to 42 percent of normal-weight adolescent
boys.  Clarke and Lauer (1993) found that nearly 70 percent
of obese children became obese adults.

     Rees (1990) has summarized the factors that may
facilitate the maintenance of adolescent obesity into
adulthood.  These include genetic predisposition (Bouchard,
1989); less sodium pump activity, which decreases energy
usage, making more fat available for storage (Ng et al.,
1989); defects in temperature regulation (Contaldo et al.,
1986); more active lipoprotein lipase (Smolin et al., 1987);
hyperinsulinemia, which tends to maintain the obese state
(Caballero, 1987; Danforth, 1983); less thermogenesis
(Acheson et al., 1984); adipocyte hypertrophy and
hyperplasia (Sjostrom, 1980); sex differences in body fat
distribution (Freid and Kral, 1987); and set point (Keesey,
1988).  Changes in body composition resulting from dieting
also may facilitate maintenance of adolescent obesity into
adulthood (Keys et al., 1950; Liebel and Hirsch, 1984;
Garner and Wooley, 1991).

     Psychological factors that may contribute to the
maintenance of obesity in adulthood include disturbances in
body image, low self-esteem, and stigmatization.  These
factors may make weight loss harder.  For example, an obese
person may be too embarrassed to exercise in public.

     These powerful physiological and psychological factors
increase the likelihood that obesity in adolescence will be
maintained into adulthood.

Effectiveness of Obesity Treatment

     The results of obesity treatment in adolescents have
not been impressive.  Garner and Wooley (1991) have
summarized the studies documenting the failure of dietary
programs to produce significant maintained weight losses. 
Bjorvell and Rossner (1985) found that the mean weight loss
at 6 months was 26 kg, but decreasing to 8.7 kg at 4 years. 
Kramer and colleagues (1989) found that less than 3 percent
of subjects were at or below posttreatment weight on all
followup visits.  Other researchers have documented similar
findings (Graham et al., 1983; Stalanos et al., 1984).  With
respect to obesity treatment in adolescents, Rees (1990)
reported that 85 to 95 percent of patients regain at least
as much weight as they lost and Stalonas and colleagues
(1984) found evidence that patients regain even more weight
than the initial weight lost.  Literature on restrained
eating by chronic dieters shows that dieting may result in
increased weight; restrained eaters generally weigh more and
have higher maximum weights following childhood (Laessle et
al., 1989; Tuschl, 1990), report eating less (Wardle and
Beales, 1987), and expend about 620 kcal less per day than
those with an unrestrained (nondieting) eating style (Tuschl
et al., 1990).  In addition, some studies report a tendency
for energy to be redeposited preferentially as body fat when
food intake is normalized after a period of food restriction
(Garner and Wooley, 1991; Dulloo and Girardier, 1990; Ozelci
et al., 1978).

Hazards of Dietary Treatment of Obesity

     Dieting in obese adolescents is associated with a wide
variety of physiological and psychological hazards.

Physiological Hazards

     The physiological hazards of dietary treatment of
obesity in adolescents include changes in body composition,
yo-yo dieting, and binge eating.

     Changes in body composition.  Changes in body
composition often result from decreased basal metabolic
rate, decreased lean body mass, and increased fat content. 
Several researchers have documented the reduction in basal
metabolic rate with calorie restriction (Elliot et al.,
1989; Leibel and Hirsch, 1984; Keys et al., 1950).  The few
patients who are able to maintain lower weights do so not by
normalizing eating patterns but by continuing to restrict
calories (Leibel and Hirsch, 1984).  Trembley and colleagues
(1984) studied a group of men who maintained a weight loss
of 40 kg through a running program; however, these men still
tended to maintain high fat contents compared to never-obese
runners of similar weight.  Most patients who diet regain
the weight they have lost, and there is a tendency to
restore this gained weight as fat.  Garner and Wooley (1991)
have summarized the data indicating that weight cycling
(weight loss and weight regain) results in higher weights
than before dieting.  Lean body mass decreases during
prolonged dieting (Abraham and Wynn, 1987).

     Yo-yo dieting.  Repeated cycles of weight loss and
weight gain may be associated with significant health risks. 
Hamm and colleagues (1989) have shown that the risk of death
due to cardiovascular disease is twice as high for a
gain-and-loss group compared to a weight-gain-only group.

     Binge eating.  The development of binge eating may be
related to the treatment of obesity:  chronic dieters have
marked episodes of overeating that resemble binge eating
(Garner, 1985; Polivy and Herman, 1985), and a subgroup of
obese patients meet formal criteria for the binge eating
disorder (American Psychiatric Association, 1993), the
development of which may be related to chronic dieting
(Marcus and Wing, 1987).  Excessive dieting associated with
being obese may lead to binge eating, which in turn leads to
increased obesity (Telch et al., 1988).

Psychological Hazards

     There are psychological hazards associated with dietary
treatment of obesity as well.  Smollar et al. (1987) found
that clinically significant weight loss was associated with
risk of adverse mood changes.  This parallels the finding by
Stunkard and Rush (1974), who reported "dieting depression." 
Although dieting depression has not been studied
systematically, repeated failure at maintaining weight loss
is likely to be associated with significant loss of
self-esteem in obese individuals who have dieted.

Hazards of Dieting in Nonobese Adolescents

     Because at least half of the adolescents who are
dieting are not overweight, the implications of dieting in
the nonobese population must be considered.  Many teenagers
who are at or below normal weight consider themselves
overweight and therefore may be prone to respond to any
national initiative to lose weight by dieting. 

Physiological Hazards

     The physiological hazards of dieting include
development of semistarvation, decreased or inadequate
deposition of bone mineral stores, and delayed menarche or
amenorrhea.

     Weight loss in normal or underweight adolescents can
result in semistarvation, which has well-known physiological
complications (Powers, 1990; 1994b).  These complications
include:

     o    gastrointestinal changes such as delayed gastric
emptying and increased liver enzymes;

     o    cardiac changes such as arrhythmias,
electrocardiogram changes, and decreased cardiac
performance;

     o    endocrine findings, including "sick" euthyroid
syndrome, low luteinizing hormone, low follicle stimulating
hormone, and low estradiol;

     o    hematologic changes such as anemia; and

     o    brain complications, including cerebral atrophy,
enlarged ventricles, and electroencephalogram abnormalities.

     Failure to gain weight during the growth spurt may
result in short stature or delayed menarche (Powers and
Root, 1987).  Patients who develop amenorrhea during weight
loss may have to gain back more weight than they lost when
amenorrhea began (Frisch, 1988).

     Adolescent girls with anorexia nervosa who have periods
of significant weight loss as brief as 1 year are prone to
develop osteopenia, or decreased or inadequate bone stores
(Bachrach et al., 1990).  Furthermore, even if menses occur,
anovulatory cycles (which may be associated with decreased
fat content) are associated with decreased bone mineral
stores (Prior et al., 1990).

Psychological Hazards

     Psychological problems commonly develop during dieting,
and the risk of developing an eating disorder is
particularly high during adolescence when dieting behavior
is rampant.

     Keys and colleagues (1950) found that a group of 36
psychologically normal males who were placed on about half
their normal caloric intake--what is now considered a
conservative treatment for obesity (Stunkard,
1987)--developed
significant emotional and behavioral changes
during weight loss (see also Garner et al., 1985).

     Adolescent dieters experience increased incidence of
anorexia nervosa, bulimia nervosa, and the binge eating
disorder. (Foreyt, 1987; Garner, 1985; Keys, 1986; Wooley
and Wooley, 1984).  Both obese and lean dieters eat more
when depressed than nondieters (Baucom and Aiken, 1981;
Polivy and Herman, 1985).

     Food restriction is associated with a variety of
physiological and psychological complications in both obese
and nonobese groups.  Because many nonobese teenagers
perceive themselves as overweight, caution must be exercised
to ensure that interventions intended for the obese are not
also implemented by the nonobese.

Treatment Strategies

     Treatment of obese adolescents should be based on two
underlying principles:  (1) "do no harm," and (2) "if it
ain't broke, don't fix it."  Because the preponderance of
evidence indicates that caloric restriction is ineffective
and possibly harmful, dieting should not be recommended. 
Current treatment methods are unlikely to result in
significant weight loss in the majority of obese
adolescents.  However, several recommendations are likely to
improve the physiological and psychological health of obese
adolescents.

     o    Decrease dietary fat and increase complex
carbohydrates.

     o    Aim toward normal nutritional intake without
restriction below usual calories needed for age and height.

     o    Improve physical fitness to reverse some of the
metabolic consequences of obesity--e.g., exercise improves
sensitivity to insulin even without weight loss (Rees,
1990).

     o    Provide psychosocial support and take steps to
prevent low self-esteem or body image disturbances.

Public Education Goals

     Goals for public education programs targeted to and for
adolescents need to emphasize public acceptance of a range
of normal body sizes and shapes.  They also must recognize
that the physiological and psychological hazards of dieting
outweigh the possible benefits.  Food restriction decreases
basal metabolic rate, decreases lean body mass, and, with
the almost inevitable regaining of weight, may increase
total fat content compared to the period before dieting.


SMOKING AND WEIGHT--Bonnie Spring, Ph.D.

     Smoking is the largest preventable cause of death and
disease.  One of every six deaths is caused by smoking. 
That is, each year 390,000 deaths in the United States--from
cardiovascular disease, cancer, and chronic obstructive lung
disease--result from smoking (U.S. Public Health Service,
1988).  Data indicate that 27 percent of U.S. adults smoke
(U.S. Public Health Service, 1990), even though 93 percent
believe smoking harms health and 70 percent wish to quit
smoking (U.S. Public Health Service, 1990).  There is a
50-percent reduction in probability of death (over 15 years)
for a person who quits smoking at age 50 (Kawachi et al.,
1993; LaCroix et al., 1991; U.S. Public Health Service,
1990).

     Barriers to quitting smoking, according to current
young adult smokers, include gaining weight (57.9 percent of
women, 26.3 percent of men), feeling tense and irritable
(67.7 percent of women, 62.1 percent of men), and enjoying
smoking (50.9 percent of women, 50.4 percent of men) (Pirie
et al., 1991).  The U.S. tobacco industry capitalizes on
women's fear of weight gain, spending an average of more
than $10 per person, or $3.3 billion annually, on
advertising (Morbidity and Mortality Weekly Report, 1990;
Warner et al., 1992).

Weight Gain and Smoking Cessation

     Evidence suggests that smoking suppresses body weight. 
In 31 of 41 studies, or 76 percent, those who begin smoking
lose weight, and smokers who quit smoking gain weight
(Klesges et al., 1989).  Average weight gain after smoking
cessation is 8.4 pounds in females and 6.2 pounds in males
(Williamson et al., 1991).  Approximately 10 percent of
males and 13 percent of females experience a major weight
gain, defined as more than 28 pounds, after quitting
smoking.

     Some predictors of major weight gain after quitting
smoking in both sexes appear to include:

o    African-American heritage;

o    age under 55 years; and

o    smoking more than 15 cigarettes per day.

     For females, being underweight and sedentary further
contribute to a postcessation weight gain (Williamson et
al., 1991).  Potential mechanisms linking smoking and weight
gain are physical activity, metabolism, and food intake. 
Longitudinal studies examining the effects of smoking
cessation on acute changes in dietary intake--both inpatient
(Gilbert and Pope, 1982; Hatsukami et al., 1984; Leischow
and Stitzer, 1991; Spring et al., 1991) and outpatient (Hall
et al., 1989; Perkins et al., 1990; Stamford et al.,
1986)--show an
increase in consumption of 179 to 383 calories per
day.  

     In general, those who are successful at smoking
cessation gain more weight than those who are not
successful.  Underweight individuals gain more weight than
those who are overweight.  Studies exploring the
relationship between weight concern and smoking relapse
reveal the following.

o    Ex-smokers are 10 times less likely than current
smokers to endorse weight loss as important (Klesges et al.,
1988b).

o    Never-quitters are almost five times more likely than
attempters to say that weight control is the most important
life quality factor (Klesges et al., 1988b).

o    For both males and females, lack of expectation that
quitting will cause weight gain predicts cessation and
abstinence at a 6-month followup (Klesges et al., 1988a).

o    Nonrelapsers have less concern about weight than do
relapsers, and concern tends to decrease even as they are
gaining weight (Streater et al., 1989).

     Therefore, appropriate goals for public messages
regarding smoking and body weight are to minimize excessive
weight concern, educate about the small magnitude of
smoking's weight-suppressing effect, and educate about the
relative health risks of smoking versus the weight gain
associated with cessation.  The target audience of these
messages should be adolescent females and adult women. 
Candidates for weight gain prevention include the already
obese, those at risk for major weight gain, and highly
weight-conscious individuals.
 
Weight Gain Prevention Strategies

     Interventions to prevent weight gain after smoking
cessation should aim at enhancing (or at least not
undercutting) cessation, decreasing energy intake
(particularly of sweet and high-fat foods), and preventing
reduced energy expenditure or compensating for increased
energy intake by increasing energy expenditure.  Enhancing
tolerance of weight gain is necessary if a basic
incompatibility exists between weight maintenance and
smoking cessation. 

     Strategies to prevent postcessation weight gain include
caloric restriction and pharmacological agents.  Effective
strategies and agents enhance abstinence; ineffective
strategies and agents undercut abstinence.

     Caloric Restriction.  Dieting while quitting smoking
seems to promote a relapse to smoking.  As a study by Hall
and colleagues (1992) has suggested, possible mechanisms may
include treatment complexity and increases in the
reinforcing efficacy of nicotine produced by food
deprivation.  In the study, which examined relapse and
weight gain prevention, participants who had completed a
2-week smoking cessation program (involving seven 1.5-hour
sessions) were randomly put into three groups for 6 weeks.

o    The control group held no meetings until week 6.

o    The innovative group weighed each participant each
morning.  If 2 pounds were gained, an individualized calorie
reduction plan was implemented.  Each participant also had
an individualized exercise plan.  Behavioral self-management
was emphasized.  This group met twice a week for weeks 1
through 3 and weekly for weeks 4 through 6.

o    The nonspecific group aimed to prevent weight gain. 
Educational presentations were made, and group discussions
about nutrition, exercise, and eating were held.  This
group, like the innovative intervention group, met twice a
week for weeks 1 through 3 and weekly for weeks 4 through 6.

     More individuals stayed abstinent from smoking in the
control group at week 6 (57 percent) than in both other
groups (50 percent in the innovative group, 41 percent in
the nonspecific group), and this continued to week 52 (35
percent in the control group, 21 percent in the innovative
group, 22 percent in the nonspecific group).

     A possible reason for such failures of behavioral
weight control interventions during smoking cessation is an
attitudinal bias in the weight intervention groups with the
subjects placing more importance on weight than cessation. 
As already noted, another reason may be treatment
complexity.  Yet another may be biological incompatibility
between maintaining cessation and restricting dietary intake
because sweets and carbohydrates offer an alternative source
of reward and may have a beneficial effect on withdrawal
symptoms.

     Pharmacological Agents.  Among pharmacological agents
for quitting smoking are nicotine gum, which may or may not
prevent weight gain, and the nicotine patch, which has not
been tested adequately.  Serotoninergic agents
(d-fenfluramine, fluoxetine) and phenylpropanolamine prevent
weight gain.  Concerns in the use of these pharmacological
agents include side effects, potential tolerance to
weight-maintaining effects, and regaining weight after
discontinuing the drug.

Conclusions

o    Nicotine has a small weight-suppressing effect.

o    Women are especially responsive to the weight control
benefits of smoking.

o    For most people, the weight gain after smoking
cessation poses trivial health risks in comparison with the
risks posed by smoking.

o    Weight gain prevention efforts may be indicated for the
already obese, for those at risk for major weight gain, and
for highly weight-conscious individuals who would not
otherwise attempt smoking cessation.

o    Attempts to diet and quit smoking simultaneously appear
contraindicated because they seem to promote the risk of
smoking relapse.

o    Pharmacologic approaches to weight gain prevention may
hold promise; however, both their side effects and duration
of benefit warrant careful consideration.

o    Attitudinal modifications about postcessation weight
gain may be most important in preventing relapse to smoking.


THE ROLE OF PHYSICAL ACTIVITY IN THE PREVENTION AND
MANAGEMENT OF OBESITY--Arthur S. Leon, M.D.

     Since 1900, the prevalence of obesity per 100,000
individuals has doubled, despite a mean decrease of 10
percent in energy intake.  The increase in obesity can be
attributed to a decrease in physical activity.  Decreases in
physical activity often lead to obesity, just as obesity
often leads to decreases in physical activity (Pi-Sunyer,
1988).

     The dynamics of energy balance between caloric input
and exercise output are essential considerations in weight
management.  When there is more input of food energy than
output of energy from resting metabolic rate, physical
activity, and the thermic effect of food, the balance is
positive and weight (fat) is gained.  A positive energy
balance of 100 kcal per day means that over 1 year the
caloric energy intake surplus amounts to 36,500 kcal, and
the expected gain in body weight (fat) is 10.4 pounds per
year (0.90 pounds per month).  However, when energy output
is greater, the balance is negative and weight is lost.  A
modest negative energy balance of 200 kcal per day (100 kcal
from reduced food intake and 100 kcal from increased energy
expenditure from, for example, walking or jogging 1 mile per
day) means that the energy deficit over 1 year is 73,000
kcal, and the predicted weight loss is 20.8 pounds (1.7
pounds per month).

     The adverse effects of very-low-calorie diets on the
body are additional reasons to consider increasing physical
activity as an aid for weight control.  If the balance
becomes too negative (e.g., -1,000 kcal per day) as the
result of such diets, adverse effects can include ketosis;
dehydration and electrolyte disturbances; elevated uric
acid; body composition changes (losses of body water, bone
mass, lean body mass); myocardial atrophy (which may result
in congestive heart failure or sudden death); psychological
changes (apathy); reduced physical activity; weight
plateauing; rapid rebound weight gain upon refeeding; and a
"rhythm method of girth control."

     Another reason for using exercise in a weight
management program is that obesity, especially abdominal
obesity, is a risk factor for atherosclerotic cardiovascular
disease that can be favorably impacted by endurance
exercise.  Other risk factors favorably impacted by exercise
include blood pressure; blood lipids and lipoproteins
(raising HDL, lowering triglycerides); glucose-insulin
dynamics (improved cell insulin sensitivity); and hemostatic
factors (lowering blood fibrinogen levels and platelet
aggregation--and thus the risk of thrombosis--and raising
tissue plasminogen activator so as to maintain fibrinolysis
or dissolve clots) (Leon, 1991).

     Regular aerobic exercise also may provide psychological
benefits.  These include improved perceived self-control,
self-confidence, and self-image; feelings of well-being;
improved stress tolerance; muscle-relaxant and tranquilizing
effects; reduced mental depression; and possibly positive
changes of detrimental health habits (Leon, 1989).

     Several metabolic mechanisms produce the favorable
effects of physical activity on weight control.  In addition
to the increased energy expenditure during physical
activity, the resting metabolic rate postexercise is
increased for 40 to 90 minutes.  The thermic
(heat-producing) response to food is also increased (Leon,
1989). The favorable effects on body composition include
enhanced fat mobilization, especially in the abdominal
region; an increase in or preservation of lean body mass;
and increased bone mass.  Better appetite control is a
possibility because of temporary appetite suppression
following exercise and a failure to compensate for energy
output by increased food intake.

     Such favorable metabolic effects were demonstrated in a
study of six obese young men undergoing a 16-week walking
program (Leon et al., 1979).  The men exercised by walking
on a treadmill for 90 minutes, five times a week, over 16
weeks.  Overall, they decreased their body weight by 12.5
pounds.  They also lost approximately 25 percent of their
body fat, reducing their fat weight from 23 to 17 percent,
while slightly increasing their lean body mass.  Other
favorable outcomes included reduced heart rate and blood
pressure and improved glucose tolerance.

     Increased physical activity and improved fitness also
contribute to improved quality of life, particularly during
aging (Voorrips et al., 1993).  In addition to psychological
benefits and subjective feelings of health and fitness,
maximum oxygen consumption increases and thus
cardiorespiratory endurance; muscle mass and bone density
also increase and thus strength; and motor performance,
reaction time, flexibility, and balance are improved.

Treatment Strategies

     Strategies to promote physical activity for weight
maintenance and treatment of obesity include making a
conscious effort to increase physical activity throughout
the daily routine and giving a high priority to setting
aside permanently a block of time specifically for
exercising at least three to five times a week (Leon, 1989). 
Safe types of exercise for obese individuals include both
weight-bearing activities (walking, stair climbing,
simulated skiing and cross-country skiing, low-impact
calisthenics and aerobics) and non-weight-bearing activities
(swimming, bicycling and stationary cycling, circuit-weight
training).  Weight-bearing activities use more energy per
unit of time than non-weight-bearing activities.  However,
obese individuals should avoid running, jumping, or vigorous
calisthenics at the onset of a fitness regimen.

     Particularly helpful for many obese people is
circuit-weight training, one of the non-weight-bearing
activities. Circuit-weight training is a series of different
weight-lifting exercises performed in a preestablished
exercise-rest sequence (McArdle and Toner, 1988).  Weights
are lifted at 30 to 40 percent of peak strength (that is,
maximum weight that one can lift once).  There are usually 8
to 12 stations per circuit, 15 to 22 repetitions every 30
seconds per station, and 15-second rest intervals between
stations. Each circuit-weight training session provides 20
to 30 minutes of exercise, and the total energy cost per
session for a 200-pound person is 360 kcal per 30 minutes
(which is equivalent to jogging at a 5-miles-per-hour rate). 
Bonuses of circuit-weight training are increases in skeletal
muscle mass/strength and resting metabolic rate.

     Guidelines for safe aerobic exercise (Leon, 1989;
McArdle and Toner, 1988) include the following:  

o    Medical screening or clearance--Those over age 40,
particularly those with other risk factors for coronary
heart disease, should obtain a medical screening or
clearance.  A graded exercise test should be included.

o    Warmup and cool-down--Sessions should begin and end
with 5 to 10 minutes of light aerobic/flexibility
activities.

o    Frequency--Aerobic exercise should be performed at
least three to five times per week.

o    Duration--Sessions should begin with 10 to 15 minutes
of aerobic activities and progress to 30 to 60 minutes per
session.  The goal should be energy expenditure of at least
300 kcal per session.

o    Intensity--Maximum oxygen consumption should be 40 to
80 percent, which is equivalent to about 60 to 90 percent of
maximum heart rate.

     To reduce the risk of coronary heart disease, 30 to 60
minutes of low- to moderate-intensity physical activity per
day, plus 1 hour of moderate to vigorous exercise per week,
appears to be optimal.  Furthermore, a goal should be for
men to maintain their maximal aerobic capacity at the 10 MET
level and for women at the 9 MET level.

     Both the general population and obese individuals have
reported barriers to regular exercise (Leon, 1989).  Among
these are perceived lack of time, willpower, and
self-discipline; lack or inaccessibility of facilities; and
fear of associated injury.  Additional barriers reported by
obese individuals include discomfort, boredom, and
embarrassment.

     Suggestions for weaving more physical activity into
daily routines are to:

o    move around more at work, in the home, and for
transportation;

o    take the stairs instead of using elevators (energy cost
for a 200-pound person walking upstairs is 23 kcal per
minute, downstairs 9 kcal per minute);

o    walk at least part of the way to work, and park at a
distance while shopping (energy cost for a 200-pound person
walking 1 mile in 20 minutes is 106 kcal);

o    be more active around the house, yard, and garage;

o    choose active recreational pursuits (dancing, bowling)
in place of sedentary ones (watching television);

o    do desk exercises;

o    stand as much as possible instead of sitting; and

o    take walking breaks every hour and in place of--or for
at least part of--coffee and lunch breaks.

Conclusion

     Recent interest in physical activity for weight
management has markedly increased.  Two reasons are the
adverse effects of very-low-energy diets in management of
obesity and the failures in maintaining weight losses from
dieting.  Other reasons include the favorable metabolic
effects of increased physical activity on energy balance,
weight control, and body composition; the improvements in
the quality of life, particularly during aging; and the
reduced risks for cardiovascular disease because of both
reverses in the metabolic and physiologic risk factors
associated with obesity as well as its independent effect on
cardiovascular risk (Leon, 1989).


SOCIOCULTURAL ASPECTS OF OBESITY--Jeffery Sobal, Ph.D.,
M.P.H.

     Sociocultural factors may be the most important
influences on the prevalence of obesity (Sobal and Stunkard,
1989; Sobal, 1991c; Sobal et al., 1992).  Social patterns,
social explanations, and social consequences of obesity are
important to consider.  From a public health standpoint, the
intended outcome of implementing a national education
program on weight and obesity is to decrease the prevalence
of obesity, not necessarily to treat it.  Viewing obesity in
the larger context of social and cultural values provides
much insight into the underlying factors influencing
obesity.

Social Patterns of Obesity

     Using a social epidemiology approach, the following
demographic patterns of obesity emerge.

o    Age--Obesity increases with age, until it begins to
decline in the elderly. 

o    Sex--Females are more likely to be obese than males.

o    Race--Caucasians are less likely to be obese than other
races.

o    Parity--Parous women are more likely to be obese than
nulliparous women.

o    Socioeconomic status--Lower-status women are more
likely to be obese than  middle- or upper-status women and
all men.

o    Marital status--Married men are more likely to be obese
than unmarried men.

     A social epidemiology approach is often employed to
identify target groups, develop screening strategies, and
tailor interventions to various audiences.  One risk of
applying this social epidemiology approach, however, is the
tendency to place blame on the obese person.  An
epidemiological approach may stigmatize obese individuals
for factors over which they may have little control.  But
when these same variables are viewed from a social science
approach, the emphasis is placed on the sociocultural
aspects of obesity rather than on demographic, biological,
or physiological characteristics.  Using a social science
approach, the following social patterns of obesity emerge:

o    Life-cycle stage (age)

     --  role timing and duration

o    Gender (sex)

     --  social norms and social power

o    Ethnicity (race)

     --  subcultural values and beliefs

o    Socioeconomic status

     --  education
     --  knowledge and beliefs
     --  income
     --  resource access
     --  occupation
     --  lifestyle

o    Marital status

     --  obligations and social support

o    Parenthood

     --  role demands

     By reconceptualizing the variables into social and
cultural factors, a different perspective can be gleaned
about factors related to obesity that possibly may be
influenced or changed.

Social Explanations of Obesity

     From a broad-scale perspective, culture is one of the
primary influences on predictors of fatness and obesity.  In
traditional societies, fatness is valued; in developed
societies, thinness is valued.  A quantitative
cross-cultural study by Brown and Konner (1987) showed that
81 percent of traditional cultures valued fatness as the
ideal in feminine beauty.  Brink (1989) has shown that
fatness enhances a woman's marriageability in many cultures. 
Social development--that is, helping societies change their
value systems about thinness, exercise, and low-fat
diets--may be the intervention goal. 

     From a social science perspective, a whole range of
nested factors can be investigated about obesity.  These
include:

o    Immediate causes

     --  motivation, behaviors, skills

o    Underlying causes

     --  knowledge, attitudes, norms

o    Basic causes

     --  roles, relationships, social structure

o    Ultimate causes

     --  values, resources, power

Changing the prevalence of obesity means changing society at
one or more of these levels.

Weight and Obesity Interventions

     Theories about the causes of obesity are important
because they guide assessments and interventions.  Implicit
theories and assumed theories may mislead program planners
because different theories suggest very different programs
and interventions.  The three main interventions for obesity
are education, resources, and proper environment.  Education
interventions can provide information, skills, and values. 
Resource interventions can supply services, support, and
finances.  Environmental interventions require adequate
access and availability of resources.  

     Interventions may focus on obesity, health behaviors,
and environmental changes.  Interventions that focus on
obesity itself emphasize the symptom and not the underlying
causes.  Such obesity-focused interventions mix voluntary
(environmental) with involuntary (genetic) causes, which is
inappropriate because individuals are unable to change their
genetic makeup.  Furthermore, health and appearance
motivations are combined, which can lead to some negative
health effects.  Hayes and Ross (1987) showed that most
people are concerned about obesity and overweight because of
their effect on appearance and not for health reasons.

     Interventions focusing on health behaviors can avoid
some but not all of the psychological and social harm to
obese people by emphasizing the positive benefits of
voluntary actions.  Health behavior interventions also may
help to prevent other health problems.

     Interventions focusing on environmental modifications
avoid individual blame and stigmatization, provide benefits
to everyone, and combine prevention and treatment.  

Social Consequences of Obesity

     In our society, the psychological consequences of
obesity include a concern and anxiety about weight that may
coincide with "dieting depression," low self-esteem,
negative self-image, and hopelessness.  Negative social
consequences of obesity include stereotyping, prejudice,
stigmatization, social isolation, and discrimination.  Such
discrimination can affect opportunities in education,
employment, promotion, earnings, housing, marriage, and
group membership.    

     The following list shows a four-component model (Sobal,
1991b) developed for coping with the negative social
consequences of obesity.  The components include
recognition, readiness, reaction, and repair.

1.  Recognition

     o    Development of awareness that obesity is
stigmatizing
     o    Gaining of insight, information, and understanding
about stigma

2.  Readiness

     o    Anticipation of settings and people involved in
stigmatization
     o    Preparation for stigmatizing acts
     o    Prevention of stigmatization by
information/exposure control

3.  Reaction

     o    Immediate coping with stigmatizing acts
     o    Longer-term coping with stigmatizing acts

4.  Repair

     o    Repair of problems from stigmatizing acts
     o    Recovery from problems resulting from
stigmatization
     o    Restitution and compensation for stigmatization
     o    Reform of stigmatizing actions and values of
others

Conclusion

     The principles of biomedical ethics (Beauchamp and
Childress, 1989; Sobal, 1991a)--autonomy
(self-determination), beneficence (helping), nonmaleficence
(avoiding harm), and justice (fairness)--must be kept in
mind when dealing with the problem of obesity.  Applying a
social perspective to the stigma of obesity can restructure
the issue by showing that the problem is not only a physical
issue based on the stigmatizing characteristic but also a
social problem that can be addressed using insights and
interventions from sociology.


GENERAL DISCUSSION

     Dr. William Dietz, American Academy of Pediatrics,
commented on Dr. Powers' emphasis on the risks of dieting in
adolescents versus the benefits, stating that little support
exists for the position that dieting has negative effects in
normal-weight individuals.  He also stated that a modest
calorie reduction does not induce semistarvation in
adolescents.  Dr. Sobal responded that reducing fat rather
than calories in the diet should be the focus in
establishing healthy eating habits.  He suggested that the
name of the initiative be changed to reflect an emphasis on
healthy eating and exercise habits rather that on obesity
and weight.  Dr. Ritenbaugh observed that in her research
with adolescent girls, the word "fat" is sometimes used to
invoke social support.  That is, when girls say to their
friends that they are fat what they are really looking for
is acceptance and support and for their friends to tell them
that they are not fat.

     Dr. Robert Jeffery, University of Minnesota, agreed
with Dr. Dietz, stating that the hazards of dieting are a
controversial issue.  He also disagreed with Dr. Powers'
statement that there are no health benefits to dieting for
normal and slightly overweight people and noted that
upper-middle-class women who typically "watch what they eat"
are the healthiest of all populations in the United States. 

     Dr. Peter Wood, Stanford University, stated that
physical activity should be stressed to adolescent girls,
particularly the ones who are dieting, and that physical
activity and a healthy lifestyle should serve as
cornerstones of the NHLBI OEI.  He also stated that
encouraging physical activity may help combat the weight
gain after smoking cessation.

     Nancy Summer, Council on Size and Weight
Discrimination, stated that fat people generally have a lack
of trust of doctors' advice on the health risks of obesity. 
She recommended minimizing the obesity prevention message
and, instead, concentrating on the benefits of healthy
eating and the joys of physical activity.  She also
suggested eliminating competition in school sports programs.

     Dr. Dietz suggested keeping the terms "physical
fitness" and "exercise" separate and clearly defined because
the two terms represent different energy costs.

     Dr. Sue Kimm, University of Pittsburgh School of
Medicine, stated that information is still needed on
childhood obesity and prevention.  She recommended providing
continuing medical education to physicians on childhood
obesity.  

     Dr. Susan Yanovski, National Institute of Diabetes and
Digestive and Kidney Diseases, echoed Dr. Kimm's comments on
the need for educating physicians about obesity, adding that
physicians too often feel that obesity is a moral weakness.

     Dr. Patricia Elmer, University of Minnesota, noted that
physical activity is not valued in many cultures except for
an elite group of athletes.  She stated that not only do
workers employed in manual types of labor seldom spend their
leisure time engaged in physical activity, but also the
normal leisure time activity for our society is "taking it
easy."


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PANEL 4:  COMMUNICATION STRATEGIES FOR EDUCATING THE PUBLIC

     The fourth panel focused on communication strategies
for educating the public.  John McGrath, chief,
Communications and Marketing, NHLBI, and chair of the panel,
provided a brief overview of how target audience
identification and segmentation fit into the NHLBI's
information campaign strategies.  Dr. Janice E. Williams,
Stanford Center for Research in Disease Prevention, used the
Stanford Five-City Project to illustrate the social
marketing principle of audience segmentation as a strategy
for targeting adults.  Dr. Thomas N. Robinson, Stanford
Center for Research in Disease Prevention, supported the use
of a population-based approach to intervention rather than a
selective high-risk approach in communication strategies for
targeting children and adolescents.


INTRODUCTION AND OVERVIEW--John McGrath

     In setting the stage for the presentations on
communication strategies, background was provided about
NHLBI communication activities in three broad areas:

o    the role of communication strategies in NHLBI
communication programs;

o    the environment in which health messages are developed
and disseminated; and

o    the publics that NHLBI programs seek to reach.

Communication Strategy

     One of the early activities that the NHLBI undertakes
as part of an education program or initiative is the
development of a communication strategy.  Typically, the
strategy:

o    summarizes the health issue and the scope of the
problem;

o    identifies primary and secondary target audiences;

o    develops possible messages for the audiences (messages
should be tested with the target audiences before full
development); and

o    identifies appropriate channels for the messages.

The communication strategy document is reviewed by all major
stakeholders in a field and provides a focus for the
communication activities of all those stakeholders.

Environment for Health Messages

     Health messages for publics and patients developed at
the NHLBI are created within an environment accustomed to
applying a scientific process to solving problems.  For
example, when a community of researchers identifies a
problem, they typically design an experiment to test various
interventions and move toward consensus on which
intervention is most efficacious for which group of people. 
In some instances, surgery may be required to correct a
condition; in other instances, a pharmacological agent may
help manage a condition; and for some conditions, research
has shown that lifestyle modification can control or prevent
a condition.

     Within this environment, it is tempting to view mass
media as an intervention that can help prevent or manage a
condition.  If mass media could be applied as such an
intervention, a fairly simple mass media health model could
be constructed.

o    Health professionals have information that can prevent
or control a condition.

o    Health professionals could package the information in a
clever way and get it to the people at risk or who have a
certain condition (i.e., use mass media to intervene).

o    People at risk would use the information to avoid or
control the condition.

Fortunately, both human behavior and the mass media are more
complex.  And as several of the following presentations
point out, mass media may not be the single intervention
that can help people control or manage a condition, yet mass
media can play a crucial role in raising awareness and in
placing an issue on the public agenda.

Publics

     Several of the communications strategies developed for
other NHLBI national education programs use the terms
"population strategy" and "high-risk strategy."  The
population strategy targets an entire population with a
message such as "have your blood pressure checked" or "eat
less saturated fat and cholesterol to lower your risk of
heart disease."  The high-risk strategy targets individuals
at particularly high risk of suffering the consequences of a
disease with a message such as "If you have high blood
pressure, stay on your treatment, watch your weight, and cut
your salt."

     Yet if one strategy for an entire population is
adopted, it should be recognized that not everyone in the
population will respond to that strategy in the same way. 
In reality, as product marketing has demonstrated, there is
no one "general public" but rather a variety of publics that
respond quite differently to different messages.  So a major
challenge of the NHLBI OEI will be to segment the publics in
a way that makes sense from a programmatic and economic
point of view.


AUDIENCE SEGMENTATION AS A STRATEGY FOR TARGETING
ADULTS--Janice E. Williams, Ph.D.

     Social marketing strategies are being applied
increasingly to public health interventions (Manoff, 1985). 
The underlying guiding philosophy of social marketing is
similar to that of its derivative--commercial marketing;
that is, to increase the likelihood of the occurrence of an
intended outcome in a campaign, planners need to develop
their offerings from the perspective of the consumer
(Lefebvre and Flora, 1988).  As for public health, this
philosophy implies that campaign planners would be well
served by employing strategies that increase their
understanding of their target audience and by developing
programs that derive from those insights.

     Audience segmentation is the social marketing strategy
most directly concerned with understanding target audiences
(Slater and Flora, 1991).  This procedure partitions a
large, undifferentiated group into smaller homogeneous and
mutually exclusive subgroups.  Segmentation analyses may be
based on a number of attributes, including demographics,
values and lifestyles, channels of communication, attitudes,
preferences, and so on (Weinstein, 1987; SRI International,
no date).  Ideally, segmentation variables bear either a
theoretical or an empirical relationship to the outcome
behavior.  Data gathering and subgroup classification can be
carried out using either qualitative and quantitative
methods.  Qualitative methods (e.g., focus groups, indepth
interviews) provide many details about the target audience. 
Quantitative methods (e.g., surveys) provide fewer details
but more structure.

     The following is an example of audience segmentation by
weight success in which the three main steps in a
segmentation analysis were illustrated.  Data were derived
from the Stanford Five-City Project--a long-term health
information campaign conducted in northern California
(Farquhar et al., 1985a).
 

Segmentation by Weight Success

     A cohort of men and women ages 25 to 55 years was
selected from the Five-City Project data set and
differentiated by weight success.  Both pregnant women and
individuals whose physical activity had been restricted for
medical reasons were excluded.  Weight success was defined
in one of three ways:

o    normal body weight at year 1 and at year 5 (for males,
normal weight was defined as a BMI less than or equal to
26.4; for females, it was a BMI less than or equal to 25.8);

o    overweight at year 1 and achievement of normal weight
by year 5 (for males, overweight was defined as a BMI
greater than or equal to 26.4; for females, it was a BMI
greater than or equal to 25.8); and

o    overweight at year 1 and loss of a minimum of 2 BMI
units by year 5.

Segmentation Through Signal Detection

     The first step in the analytic process was to establish
mutually exclusive, homogeneous subgroups.  The sample was
stratified by gender assuming that men and women have
different pathways to weight success.  The segmentation task
was approached quantitatively, using signal detection, a
form of recursive partitioning (Kraemer, 1992).

     Five sets of segmentation variables were considered:

o    behavioral (vigorous and nonvigorous exercise, dietary
and smoking habits);

o    cognitive (awareness of diet and exercise CVD
prevention strategies, health knowledge, exercise and diet
self-efficacy);

o    attitudinal (behavioral intention, weight and nutrition
attitudes);

o    communication (television, newspapers, radio,
magazines, health articles, pamphlets, interpersonal
discussion); and

o    experimental condition (treatment versus control city).

     Demographic variables were excluded to provide the
psychosocial variables maximum potential for discriminating
subgroups.    

     Signal detection analysis resulted in six audience
subgroups for the males.  Four model variables were
significant in determining those groups:  behavioral
intention, exercise self-efficacy, nutrition attitudes, and
change in diet self-efficacy.  The attitudinal and cognitive
variables drove weight success for men; experimental
condition was not a predictor of weight success.  

     The male subgroups were characterized as follows:

o    Subgroup 1

     --   Low-moderate behavioral intention
     --   Low-moderate exercise self-efficacy

o    Subgroup 2

     --   Low behavioral intention 
     --   Absolute exercise self-efficacy

o    Subgroup 3

     --   High behavioral intention
     --   Low-moderate exercise self-efficacy
     --   Negative attitudes toward nutritious foods

o    Subgroup 4

     --   High behavioral intention
     --   Low-moderate exercise self-efficacy
     --   Positive attitudes toward nutritious foods

o    Subgroup 5

     --   High behavioral intention
     --   High exercise self-efficacy
     --   Decrease in diet self-efficacy

o    Subgroup 6

     --   High behavioral intention
     --   High exercise self-efficacy
     --   No change or an increase in diet self-efficacy
over time.

     Signal detection analysis resulted in five female
subgroups.  Three model variables were significant:  weight
attitudes, days of reading the newspaper, and health
knowledge.  When compared to the males, there were gender
differences in the variables controlling weight success;
again, experimental condition was not a significant
predictor.

     The female groups were characterized as follows:

o    Subgroup 1

     --   Lowest control over eating behavior and weight

o    Subgroup 2

     --   High control over eating behavior and weight
     --   No days of reading the newspaper

o    Subgroup 3

     --   Moderate control over eating behavior and weight
     --   One or more days of reading the newspaper
     --   Lower health knowledge

o    Subgroup 4

     --   Moderate control over eating behavior and weight
     --   One or more days of reading the newspaper
     --   Higher health knowledge

o    Subgroup 5

     --   Highest control over eating behavior and weight
     --   One or more days of reading the newspaper

     The next step in the analysis was to conduct a more
refined analysis of the subgroups by examining differences
among them on demographic, behavioral, cognitive,
attitudinal, and communication variables.  The third step
was to outline campaign strategies based on the unique
attributes of each subgroup.  (These analyses for the female
subgroups are still in progress.)  For example, male
subgroup 1, a high-risk group, was one of the more highly
educated groups, was the second oldest, had relatively high
income, was mostly married, and read the newspaper. 
Subgroup 1 members possessed many of the attributes that
were likely to predispose them to healthy weight regulation,
yet they were not exercising, their dietary habits were not
particularly good, and they had a very low intention to lose
weight.  The channels, messages, and behavioral change
strategies determined most likely to be effective in
reaching subgroup 1 were as follows.

o    Channels  

     --   Newspaper supplemented by television

o    Messages  

     --   Increase exercise
     --   Increase positive dietary habits 
     --   Increase exercise self-efficacy
     --   Increase diet self-efficacy
     --   Increase intention to lose weight

o    Strategies     

     --   Modify perceived risk for illness
     --   Increase awareness of diet and exercise CVD
prevention strategies
     --   Increase awareness of excess weight
     --   Modify subjective norms
     --   Change attitudes toward men needing to lose weight
     --   Skill building
     --   Persuasive arguments
     --   Modeling
     --   Behavioral rehearsal
     --   Reinforcement

     A more successful male subgroup, subgroup 6, had the
highest educational level, was youngest, had good incomes,
tended to be married (although percentage of marrieds was
lowest as compared to their peers), and made liberal use of
print media and the radio.  This subgroup also had the
second highest level of exercise, not particularly good diet
habits, not much awareness of diet and exercise as CVD
prevention strategies, highest health knowledge, high
exercise self-efficacy, moderate diet self-efficacy, and
high intention to lose weight.  The channels, messages, and
behavioral change strategies determined most likely to be
effective for this subgroup were as follows:

o    Channels

     --   Newspapers and magazines supplemented by radio

o    Messages

     --   Maintain exercise
     --   Increase positive dietary habits
     --   Maintain health knowledge
     --   Maintain exercise self-efficacy
     --   Increase diet self-efficacy
     --   Maintain intention to lose weight

o    Strategies

     --   Skill building
     --   Persuasive arguments
     --   Modeling
     --   Behavior rehearsal
     --   Reinforcement

Conclusion

     This audience analysis resulted in subgroups that were
statistically different from one another.  Campaign planners
could decide to target each segment or collapse subgroups on
the basis of their similarity to one another (e.g., the
basis of their risk in relation to the outcome variable). 
For example, planners may want to target the high-risk
subgroups rather than the most successful subgroups.

     Audience segmentation can be a very useful tool for
helping planners to know and decide upon target audiences. 
This kind of analysis provides a basis both for formative
research with the targeted subgroups and for pretesting
proposed messages.


COMMUNICATION STRATEGIES FOR TARGETING CHILDREN AND
ADOLESCENTS--Thomas N. Robinson, M.D., M.P.H.

     A number of features of obesity among children and
adolescents make the design of a national obesity education
program particularly difficult.  One of the major obstacles
is identifying a truly high-risk group.  Four main factors
account for this.  First, physical morbidity is unusual in
obese children and adolescents.  Although being overweight
certainly puts children and adolescents at a higher risk of
hypertension, hypercholesterolemia, diabetes, and other
health problems, the truth is that the great majority of
obese children have none of these problems.  Second, most
obese children or adolescents do not become obese adults,
and most obese adults were not obese children (Stark et al.,
1981; Garn, 1985).  In addition, childhood risk factors for
clinically significant obesity, persistent obesity, or
adult-onset obesity are only weakly predictive.  In other
words, we are really unable to predict, with any reasonable
accuracy, which overweight children will have associated
health problems or remain obese into adulthood, and which
normal-weight children will grow into overweight adults. 
Similarly, we are unable to identify those most likely to
benefit from treatment.  As a result of these four factors,
our current ability to identify truly high-risk individuals
is quite limited.  These uncertainties suggest that for
public education, a population-based approach is more
appropriate than a selective high-risk approach, and any
high-risk targeting should be limited to educational
components directed at health professionals.

     In medicine, the decision to treat is often made
because of the belief that the potential benefits outweigh
the potential risks.  The principle of nonmaleficence
suggests that we must "first, do no harm."  However, in the
case of obesity, significant side effects have been
associated with both medically supervised and unsupervised
weight control treatment.  These side effects can include
labeling the child, growth failure, delayed puberty, and
significant psychological problems (Mallick, 1983; Stunkard
and Rush, 1974).  In addition, stigmatization and
discrimination are very real for overweight children and
adolescents (Brownell and Wadden, 1984).  As a result, in
many ways, obesity is much more of a social problem than a
true medical problem for children and adolescents.  Medical
legitimization of these attitudes and practices can be
particularly harmful.  The NHLBI OEI must be extremely
sensitive to these risks.  

     A desire for thinness is already pervasive in American
culture.  Some evidence suggests that dieting itself is
causally linked with bulimia (Polivy and Herman, 1985). 
Young girls appear to be particularly vulnerable to adopting
unhealthful weight regulation strategies in response to
social pressures for thinness.  For example, in an
ethnically diverse population in northern California,
research showed that by 10th grade (or about age 15),
one-third of
normal weight girls judged themselves to be
overweight or very overweight, 10 percent of girls reported
all the major diagnostic symptoms of bulimia, and an
additional 10 percent reported purging for weight control
(Killen et al., 1986, 1987).  Thus the words "obesity,"
"overweight," or even "weight control" (and their themes)
should be used only cautiously in this initiative.  If
possible, consideration should be given to change the title
of the education initiative.  The goal instead should be a
campaign promoting healthful nutrition and physical
activity, with only secondary emphasis on weight.

     The principle of nonmaleficence has a companion, the
principle of beneficence.  The Food and Drug Administration
has linked the two by following a policy of not allowing
release of new products to the public until they are proven
to be both "safe and effective."  However, the criterion of
effectiveness is often given less importance (or ignored
entirely) in the planning and distribution of
nonpharmaceutical interventions by Government, voluntary,
and private-sector organizations.  Clearly, the standard of
proven effectiveness should be followed in public education
campaigns such as that being planned by the OEI.  

Formative Research and Evaluation 

     Including a prominent evaluation component in all
interventions is the only way to ensure effectiveness.  This
evaluation should not only include outcomes but also be a
crucial part of campaign planning, development, and
implementation, and it should include audience segmentation
studies and needs analysis, pretesting of specific messages
and educational strategies, timely feedback during
implementation, and making improvements throughout the
process.  
 
     Without performing an evaluation, we cannot be
confident that our campaign is working and that it has no
detrimental effects.  Unfortunately, it is not uncommon to
find that well-meaning programs produce no effects, or even
detrimental effects.  This has been particularly true for
alcohol and other drug abuse prevention efforts.  

     The first stages of evaluation for a public education
campaign involve audience segmentation and needs analysis,
followed by pretesting.  Age, sex, ethnicity, geography, and
many other factors affect obesity, the physical and
psychosocial effects of obesity, and nutrition- and
activity-related knowledge, attitudes, and behaviors.  To
implement an effective campaign, these differences must be
understood and acknowledged in the specific objectives and
educational strategies.  In the business world, a company
would never think of launching a new product without
devoting considerable resources to this kind of evaluation. 
This preparatory evaluation, called formative research, is
how we get to know our target audiences.  Later stages of
evaluation involve process and effects (i.e., knowledge,
attitudes, behaviors, physiology).

Targeting Multiple Levels and Using Complementary Strategies

     Planning an education campaign should consider matching
up the intended target groups (or audiences) with specific
objectives (which eventually get translated into specific
messages) and appropriate educational strategies (or
channels of communication).  All this needs to be guided by
the results of formative evaluation.  Evidence from previous
attempts to change health behaviors with population-based
interventions suggests that success is more likely if
multiple levels of social organization--individuals,
organizations, and communities--are targeted.  On the
individual level, specific objectives and strategies should
be designed for children and adolescents themselves, and
parents and health professionals (with specific targeting of
pediatricians, family physicians, nurses, and
nutritionists).  Teachers and coaches also might be
included.  On the organizational level, specific objectives
and strategies involving schools, community centers, health
care facilities, restaurants, and supermarkets should be
designed.  On the community level, specific objectives and
strategies involving neighborhoods, cities, counties,
states, and the entire Nation should be designed.

     In addition to targeting multiple audiences at multiple
levels of organization, the most successful campaigns have
used multiple, complementary educational strategies. 
Educational strategies can involve electronic media
(noninteractive, interactive), print media (newspapers,
books, magazines, pamphlets, newsletters, posters, direct
mail), and face-to-face interaction (formal--workshops,
classes, counseling--and informal).  They also can be
environmental (healthy foods, recreational facilities) and
regulatory (laws, policies).  Not all educational strategies
are appropriate for every specific audience, objective, or
message.  In planning this initiative, attempts should be
made to use as many complementary strategies as possible.  

     Mass Media Strategies.  A particularly popular belief
is that mass media, and television in particular, are the
source of--and answer to--all our health and social ills. 
This belief may arise from the assumption that because
television reaches a large number of people, it therefore
must have large effects.  In reality, there are very few
examples of effective mass media interventions.  The
Stanford Three-Community Study is one of the few available
examples of mass media alone producing short-term health
behavior change, although not in increased physical activity
or sustained weight loss (Farquhar et al., 1985b).  The
Stanford Three-Community Study and a number of subsequent
studies in Finland and the United States have demonstrated
that when associated with more intensive interpersonal and
environmental interventions, television can be effective in
legitimizing a message and increasing awareness, directing
viewers to resources (like a hotline number) or places to
act (like a physician's office), or providing a reminder to
act (Farquhar et al., 1991).
 
     Although the mass media marketing model may be
appealing, selling physical activity is very different from,
for example, selling athletic shoes.  Nike ads may appear to
be promoting physical activity, but their main goal is to
sell shoes.  "Just Do It" does not refer to becoming
physically active but to hustling down to the nearest, most
convenient Nike dealer to purchase a pair of shoes.  The
process is simple, specified, and well understood, and the
obstacle of spending money can even be deferred by using a
credit card.  There are very few barriers to overcome.  The
situation for physical activity is far from similar.  Even
if children and adolescents are persuaded to become more
physically active, they need the physical resources to do it
and the willingness to overcome, for example, the
breathlessness and cramps in their sides.  This is unlikely
when only about half of the Nation's 9th through 12th
graders are even enrolled in physical education (Centers for
Disease Control, 1992).

     Television is most suited to quick-fix solutions, but
there is no quick fix for obesity.  In addition, some
interesting--and disappointing--findings come from research
on advertising influences.  For example, in controlled
studies, ads for high-fat, high-calorie snacks do appear to
influence the subsequent snack choices of children, but ads
promoting healthful snack choices do not (Jeffrey et al.,
1982; Gorn and Goldberg, 1982).  Thus, if our purpose is to
produce a significant long-term impact (and not just to pat
ourselves on the back for a highly attractive campaign), the
limits of television, and the benefits of other strategies,
must be acknowledged.  

     Potentially beneficial strategies may utilize other
noninteractive electronic media such as radio, recorded
music, and films.  Some researchers believe that music media
have been underutilized in health campaigns for adolescents. 
By mid- to late adolescence, listening to music consumes
about as much time as television viewing.  Unfortunately,
there is little information on the effects of health
messages in music media, and some studies suggest that
teenagers often completely miss the point of most songs or
music videos with messages (Christenson and Roberts, 1990).

     Technology also provides us with more interactive
electronic media.  Computers and computer games are
particularly attractive media for producing personalized,
interactive programs to guide behavior change in children
and adolescents.  The research group at Stanford University
has had very promising preliminary results using interactive
computer-based curricula.

     Print Media.  Use of the print media may include
newspapers, books, magazines, pamphlets, newsletters,
posters, and direct mail.  Unfortunately, experience
suggests that the written word does not seem to have
tremendous persuasive appeal to most children and
adolescents.  This seems to be particularly true among the
hip-hop generation (MEE Productions, 1992).  However, the
Stanford University studies have found print materials to be
useful in association with more intensive, face-to-face
interventions (Killen et al., 1988).

     Face-to-Face Strategies.  Face-to-face interventions
include workshops, classes, counseling, and even formal
medical treatment.  In addition, informal conversations
between friends may be an important focus, particularly for
teenagers who are vulnerable to the perceived expectations
of their peers.

     Environmental Strategies.  Environmental interventions
may include changing the school lunch, replacing candy
machines with fruit machines, rearranging cereal shelf plans
in supermarkets, building bike paths and basketball courts,
and making public parks safe.  Regulatory strategies may
include requirements for daily physical education classes in
kindergarten through grade 12 or insurance incentives for
adopting healthful behaviors.  Unfortunately, research on
the relative effectiveness of each of these strategies is
limited, particularly for children and adolescents.  The
most important thing here is to match the specific
objective, audience, channel, and message and, overall, to
integrate multiple, complementary strategies.

     School-Based Strategies.  The Stanford group has had
success with multiple-factor school-based interventions. 
The interventions, derived principally from Bandura's social
cognitive theory and McGuire's social inoculation theory,
mix face-to-face activities with print media, slides, music,
and videos in the classroom.  It is believed that an
appropriate application of theory is directly related to
success in achieving beneficial behavioral and physiologic
outcomes (Killen and Robinson, 1988).

     The largest of the Stanford University studies was a
randomized, controlled evaluation in four ethnically diverse
schools with a total of 1,447 10th-grade students (Killen et
al., 1988).  A 20-session intervention emphasizing skills
training for nutrition, physical activity, cigarette smoking
cessation, and stress reduction was developed.  At a 2-month
followup, a significantly higher proportion of those
students who were exposed to the curriculum had become
regular vigorous exercisers and reported beneficial changes
in their food choices, as compared to an untreated control
group.  These results were substantiated by beneficial
changes in resting heart rate, BMI, and triceps and
subscapular skinfold thicknesses.  Beneficial effects also
were demonstrated for cessation of experimental cigarette
smoking.  In addition, at a 2-year followup, the significant
differential effects were maintained for self-reports of
vigorous physical activity, food choices, and smoking, as
well as for measured resting heart rate, although not for
BMI or skinfold thicknesses.  These results suggest that it
might be feasible to influence dietary, physical activity,
and smoking behaviors beneficially for a large segment of
the population through a school-based approach.  

Summary

o    A population-based approach is preferable to a
high-risk approach.

o    First, do no harm.  Nutrition and physical activity
should be emphasized rather than obesity or weight.

o    All interventions need to be both safe and effective. 
Evaluation should be emphasized from start to finish.

o    Formative evaluation should be used to match audiences,
channels (or educational strategies), and specific messages. 
Knowing the target audience and how members will respond to
the messages is essential.

o    This initiative should attempt to integrate multiple
complementary educational strategies.


REFERENCES

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Christenson PG, Roberts DF. Popular Music in Early
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Farquhar JW, Fortmann SP, Flora JA, Maccoby N. Methods of
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Farquhar JW, Fortmann SP, Maccoby N, Haskell WL, Williams
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Farquhar JW, Maccoby N, Wood PN. Education and communication
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Garn SM. Continuities and changes in fatness from infancy
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Killen JD, Taylor CB, Telch MJ, Saylor KE, Maron DJ,
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SMALL GROUP REPORTS

     For the purpose of discussion, five potential target
audiences--children, adolescents, adults, older adults, and
minority populations--were identified.  Each small group was
assigned one of these target audiences and asked to
consider:

o    the target audience in terms of age, education,
socioeconomic status, etc., with consideration to knowledge,
attitudes, and behaviors related to weight, overweight,
eating patterns, and physical activity;

o    the content of appropriate messages related to weight,
overweight, eating patterns, and physical activity for each
target audience as well as the relationship of overweight to
cardiovascular risk and lung disease;

o    the issues of source credibility in the delivery of
messages to the appropriate target audience as it relates to
motivating the audience to action;

o    the different strategies for motivating the target
audience to act on the information--strategies such as fear
arousal, positive reinforcement, and self-image enhancement;
and

o    the communication channels that could be used to
deliver the various messages--channels such as interpersonal
contact, mass media, and print materials.



SMALL GROUP REPORT:  CHILDREN

Common Terms and Assumptions

     The facilitator of the small group, Dr. Leonard
Epstein, reviewed some of the science base and generally
accepted assumptions related to obesity among children to
lay a common foundation and provide a framework for
discussion.  The following items were listed.

o    Definitions of obesity include:

     --   20-percent overweight;
     --   85th or 90th percentile BMI; and
     --   25-percent body fat for males and 30 percent for
females.

     (No single definition was chosen.)

o    Obesity among children is increasing.  

o    There is a higher rate of obesity in girls than boys.

o    The prevalence of obesity increases at about 8 or 9
years of age.
                    
o    Obesity in children is related to cardiovascular risk
factors such as lipids and blood pressure.  

o    The etiology of obesity among children is
multifactorial and not well understood.

o    Preventing obesity in children, unlike adults, involves
two approaches.  Should we prevent children from becoming
overweight or prevent overweight children from becoming
overweight adults?  (The group did not resolve this
question.)

o    There are side effects to treating children for
obesity, including development of eating disorders.  For
example, in the Catchment Area Study, 3 to 4 percent of
those treated (mostly girls) developed eating disorders. 
Dieting, which may be a risk factor for eating disorders, is
another side effect.  Therapists can dispel or exacerbate
the feelings of stigmatization in obese children.

o    The preference for sweets is inherent from birth and
difficult to work against.

Target Audience Overview

     The target populations of children can be broadly
defined as:

o    All children under age 12.  With a population-based
approach and for primary prevention, messages should be
tailored to the developmental stage of the child:
     
     --   Infant
     --   Preschooler
     --   School-age

o    High-risk children under age 12.  With a high-risk
approach and for secondary prevention, those specifically at
risk of becoming obese adults should be targeted:

     --   Obese children (the group did not agree on a
definition)
     --   Children with obese parents or siblings or with
several cardiovascular risk factors

Priority Targets

     The group was concerned that if the NHLBI Obesity
Education Initiative targets only children at high risk,
there will probably be increases in chronic dieting and
eating disorders associated with dieting, as well as
stigmatization of obese children.  Thus, all children were
identified as priority targets.  Other priority targets are
those who can influence children, including parents and
families, physicians, teachers, child care providers, and
food manufacturers.  The group felt that primary prevention
and a population-based approach will be most effective.

     Although the small group identified the two major
target audiences as all children and high-risk children,
they focused entirely on the target audience of all children
and the population-based approach.  Developing similar
messages, motivational strategies, and channels for
high-risk children also will be an important activity for
the group on high-risk children.

Content of Appropriate Messages

     The group identified two major messages and related
specific messages for children, parents, and others who
influence them.

1.   Be more active.  (There was no consensus on specific
caloric expenditure guidelines due to the lack of scientific
data.)

o    For children

     --   Spend more time outside.
     --   Play outside with a friend.
     --   If you can't go outside, dance. 
     --   Be physically active every day.
     --   Like your body, and take care of it.

o    For parents

     --   Be more active with your child, and be a model for
your child.
     --   Support active, daily physical education in
schools.
     --   Use community resources, such as schools, YMCAs,
and parks, and transport your child to them, if necessary.
     --   Provide supplies and equipment for fun and
activities, making sure all equipment is in good condition.
     --   Encourage less sedentary behavior, perhaps by
limiting access to television and video games.  Provide
active choices, for example, by transporting your child so
he or she can play in team sports.

o    For other influential people

     --   Support good physical education in schools, and
ensure that it is not affected by school budgets.
     --   Assign homework in physical education classes.
     --   Encourage less competitive, more participatory
sports for children.
     --   Train teachers and other influential people not to
stigmatize obese children.
     --   Help children develop motor skills (jumping,
throwing a ball) at appropriate ages so that they can enjoy
physical activity throughout their lives.  The National
Association for Sport and Physical Education is working with
KinderCare, a national chain of daycare centers, to develop
guidelines.

2.   Eat less fat, and eat healthier.  The group focused on
reducing fat rather than calories.  They made no specific
recommendations on the level of fat intake due to the lack
of research and the fact that fat requirements vary with
different developmental stages.  The group made the
following recommendations.

o    For children

     --   It's cool to eat fruit.
     --   Try a new fruit or vegetable every week.
     --   Use fruit as snacks.
     --   Choose a lean "happy meal."
     --   Choose healthy, low-fat school lunches.
     --   Choose low-fat snacks and desserts.
     --   Be helpful to other children who are trying to
make changes.

o    For parents

     --   Promote social skills that encourage healthy
eating.
     --   Keep and prepare healthy foods.  Do not keep
high-fat foods like ice cream at home.  
     --   Teach preplanning and problemsolving to your child
at home and when eating out.
     --   Involve your child in food choices.
     --   Reward your child with praise and attention, not
food.
     --   Be a good role model for your child.
     --   Encourage healthy school lunches and healthy
choices from vending machines.
     --   Switch to low-fat milk and dairy products for
children over age 2.
     --   Buy substitutes for high-fat foods.
     --   Bake and broil foods instead of frying.  (Prepare
all foods in low-fat ways.)
     --   Make meals a pleasant family experience.
     --   Modify your family's favorite recipes to make them
low in fat.
     --   Pay attention to portion control.
     --   Try a new low-fat food or recipe every week.
     --   Teach your child how to prepare low-fat snacks.
     --   Keep food stored away, out of sight.
     --   Eat only in selected places in the home.
     --   Try skipping desserts.

o    For other influential people

     --   Conduct demonstrations in school cafeterias of how
to make low-fat foods.
     --   Change the media environment so that healthy foods
are marketed.

     A participant relayed some of the issues and concerns
brought up by Dr. David Levitsky, Cornell University,
regarding messages on obesity.  He has conducted food intake
studies in which he changed the fat content of young adults'
diets and found that the subjects who were blinded to the
fat content of their diet did not completely compensate for
the lower fat.  They did, in fact, consume fewer calories. 
This research has led him to these conclusions.

o    Lowering dietary fat and increasing energy expenditure
are the only ways to produce long-term changes in body
weight.  The major thrust in controlling body weight should
be on changing dietary composition, that is, lowering
dietary fat to less than 25 percent of calories, not
reducing total caloric intake.

o    Middle- to upper-class females are already so
sensitized to the effects of obesity that they are suffering
from eating disorders.  

o    Educational programs should teach weight acceptance. 
Any educational effort that encourages weight loss beyond 15
to 20 percent of total weight, except in the morbidly obese,
should be discouraged.  

     The group discussed the above and questioned whether
recommending dietary fat levels of less than 25 percent
would be appropriate for children.  

Source Credibility

     The group did not discuss source credibility.

Motivational Strategies

     The following strategies were briefly discussed by the
group.

o    Providing education, not just information

o    Encouraging skill development for putting behaviors
into action

o    Making environmental changes

     The group noted that many of the environmental changes
in the messages focus more on diet than on physical
activity.  Other environmental change strategies, such as
building sidewalks and setting up clubs and church groups,
could encourage more physical activity.  However, when
children go outside, it is essential that the environment be
safe and that the children have something active to do.

     The group also suggested that all efforts stress the
advantage--and importance--of encouraging youngsters to
engage in physical activities that will be carried over into
adulthood, such as tennis or running.

Channels for Communication

     Although messages to the various segments of the target
audiences will be similar, the channels to reach them may be
quite different.  Therefore, segmentation may occur by
income level or gender so that various channels can be used.

     Any person or organization, such as child care
providers or civic associations that have an influence on
children at any developmental stage, can be a channel for
communication.  The group identified these appropriate and
effective channels.

o    Parents and other influential adults--through magazines
and churches

o    Schools--through health education curricula,
afterschool activities, teachers acting as role models,
physical education curricula, preschool curricula,
parent-teacher
associations, and inservice sensitivity training

o    Community organizations--including churches, libraries,
scouts, YMCAs, parks, recreation programs, civic
organizations, youth service organizations and youth sports
programs, both competitive and noncompetitive

o    Health care providers, including pediatricians--through
pamphlets, advice, and continuing medical education

o    Print media--including magazines and tabloids for
children and parents

o    Electronic media, including television, radio, and
other sources of music that can provide positive role
modeling in both commercials and programming

o    Business and industry, including food manufacturers and
restaurants, insurers, advertisers, cafeterias, and child
care programs in large companies

o    Child care providers

o    Civic associations

     The group also recommended the following Government
actions.

o    Restructure USDA commodity pricing, for example, by
removing the subsidy for producing whole milk.

o    Offer tax credits and incentives for targeted
behaviors, such as worksite fitness programs.

o    Mandate daily physical education in schools.

o    Modify school lunches.

o    Build bike paths.

o    Use school facilities for the community after regular
school hours.

Additional Recommendations

o    Gather up-to-date data on various segments of the
target audiences regarding topics such as food consumption
and physical activity levels to help define messages.  For
example, it is not known how active children are now, so it
is difficult to know whether it will help to tell them to be
more active.

o    Convene a panel of experts to make recommendations to
pediatricians and other physicians about the prevention and
treatment of obesity in children.  Parents can be alerted to
weight problems before they become severe and be given
assistance in dealing with them.

o    Work with food manufacturers and other industries to
stimulate more changes. 

o    Recognize diversity of weight in children as with
height and skin color.  Focus on how to make them healthier,
as opposed to thinner, especially because making them
thinner often does not make them healthy. 

Group members:  John C. McGrath and Leonard H. Epstein,
Ph.D. (group facilitators); Lilian Cheung, D.Sc., R.D.;
Marguerite Evans, M.S., R.D.; Sue Y.S. Kimm, M.D., M.P.H.;
Paula Keyes Kun, M.S.; Eva Obarzanek, Ph.D., R.D.; Patricia
Reeves, R.D.; Claire Regan, M.S., R.D.; James F. Sallis,
Jr., Ph.D.; Elizabeth H. Singer, M.S.; Denise Sofka, M.P.H;
Nancy Summer; Maggie Pettersen, M.S. (recorder).


SMALL GROUP REPORT:  ADOLESCENTS

Target Audience Overview

     Adolescents, for purposes of identifying specific
target populations, can be broadly considered in terms of
the following. 

1.   All adolescents.  With a population-based approach and
for primary prevention, the overall audience should be
segmented and targeted by developmental stage:

o    Preadolescence:  fourth and fifth grade 

o    Adolescence:  junior and senior high school 

o    Postadolescence:  post-high school and college

2.   High-risk adolescents.  With a high-risk approach and
for secondary prevention, the following groups should be
specifically targeted.

o    Obese adolescents

o    Adolescents with eating disorders

o    Sedentary adolescents

o    Pregnant teenagers

Priority Targets

     The possibility of targeting males and females
separately was discussed, but the group did not decide
whether this was necessary or desirable.  The group
acknowledged that it might be necessary to target specific
social and cultural groups within the school-grade
developmental stages as well as individuals who were not in
school.  Of particular concern to the group was the fear
that national messages on obesity and weight might further
stigmatize high-risk adolescents.  The group agreed that the
emphasis should be placed on primary prevention and that all
adolescents should be seen as priority targets.

Content of Appropriate Messages

     The group discussed specific types of messages for all
adolescents concerning weight, weight control, healthy
eating, and physical activity.

     Messages Concerning Weight

o    Normal development

     --   Reinforce the idea that their bodies and
dimensions are changing.
     --   Evaluate what is being taught in schools.
     --   Include this subject in science curricula and
health education, not just in family planning classes.
     --   Promote messages throughout the curriculum.  

o    Broad range of safe weights and acceptable shapes

     --   Remove the idea that weight should stop changing
once height stops changing.

     Messages Concerning Weight Control

o    Weight acceptance rather than weight loss

     --   Keep in mind that boys are trying to gain weight,
while girls are trying to keep from gaining weight.
     --   Remember that many adolescents are already
sensitized to obesity and overweight.
     --   Remember that focusing on weight loss may lead to
body image disturbances, eating disorders, and decreased
self-worth.
     --   Educate teenagers on the range of healthy levels
of body fat.
     --   Keep in mind that using skinfold calipers is an
invasive procedure, particularly to teenagers who are
overweight.
     --   Know that teaching weight acceptance may help
prevent weight gain.
     --   Keep in mind that the "Freshman 10" or "Freshman
15" (i.e., the 10- or 15-pound weight increase) that many
high school graduates experience during their first years at
college may be part of normal maturation or lifestyle
changes.  Evaluate what is being taught about this on
college campuses.

o    Healthy lifestyle choices

o    Healthy eating and physical activity

     The group considered the recommendation of lowering
dietary fat to less than 25 percent of total calories as a
means to control body weight (as proposed by Dr. Levitsky)
but stopped short of promoting this message to teenagers. 
One member mentioned the public policy implications of
imposing this diet (e.g., food labeling changes) as a
deterrent.  Another felt that diet should be viewed in the
context of total health, not just for the prevention of
obesity, and suggested that messages should communicate the
potential benefits of other dietary components (such as
fiber) in reducing other morbidities.

     Messages Concerning Healthy Eating

o    Make healthy food choices.

     --   Balance
     --   Variety
     --   Moderation

o    Recognize hunger and satiety cues.

     --   Eat when hungry; stop when full.
     --   Learn to distinguish between emotions and true
hunger pangs.

     Messages Concerning Physical Activity

o    It's not optional!

o    Physical activity is not a spectator sport.

o    There is a wide range of acceptable activities other
than competitive sports.

o    There is a wide range of acceptable outcomes or
potentials.

o    Ensure balance, variety, and moderation.

o    Sweat is not gross.

Source Credibility

     The group thought the following people and institutions
are influential and could help motivate adolescents to act
on messages concerning obesity.

o    Peer groups (most powerful influence)

o    Parents

o    Role models

o    Schools

     --   Teachers (home economics, science, health,
physical education)
     --   Guidance counselors
     --   Nurses
     --   Foodservice workers
     --   Administrators
     --   Coaches/trainers

o    Health care providers

o    Government/regulatory agencies/NIH

     The group recognized the need to educate and inform
individuals or groups who will be communicating to teenagers
to make sure that accurate and consistent messages will be
delivered.

Motivational Strategies

     The group identified specific motivational strategies
relating to weight, physical activity, and healthy eating.

     Strategies for Weight

o    Educate teens about normal developmental stages.

     --   Eliminate misinformation in schools.
     --   Implement broad messages, and cross-promote
healthy messages.

o    Encourage family communication about weight
expectations and acceptance.

     Strategies for Weight Control

     The group did not develop specific strategies for
weight control.

     Strategies for Healthy Eating

o    Relate messages to image.

     --   Make behaviors acceptable to peers (e.g., include
healthy foods in more socially acceptable ways).

o    Teach adolescents survival skills to accomplish goals
by showing them how to:

     --   eat healthfully at the school cafeteria and at
fast food restaurants; 
     --   prepare healthy meals;
     --   read labels;
     --   choose healthy snacks and beverages;
     --   eat in relation to physical activity needs;
     --   recognize advertising ploys; and
     --   adopt the Dietary Guidelines for Healthy
Americans.
     
o    Provide motivators/rationale behind healthy eating
outcomes.

     --   Focus more on immediate benefits, but communicate
distant health benefits as well.
     --   Make sure what you say is true.  (Will they
really, for example, feel more energetic if they eat in a
certain way?)

o    Communicate messages in teen dialect (English
variation).

o    Keep messages up to date.

     Strategies for Physical Activity

o    Relate outcomes to image:

     --   rhythm (dancing)
     --   rosy cheeks (running)
     --   fitness (aerobics)

o    Teach adolescents how to accomplish desired behaviors
despite barriers.

     --   Peer acceptance (Show how physical activity can be
social.)
     --   Equipment/clothing (It's not critical, for
example, to have $100 air-pump sneakers.)
     --   Environmental barriers (access and availability)
     --   Time barriers (Show how physical activity can be
part of a daily routine, such as walking to school or taking
the stairs.)
     --   Misinformation (Teach teenagers how to recognize
false advertising.)

o    Discuss outcomes/expectations

     --   Provide information on immediate and distant
health outcomes.
     --   Communicate the truth.  (For example, you might
get sweaty when you exercise.)

o    Encourage developmentally appropriate activities.  (For
example, weightlifting may not be appropriate for fourth and
fifth graders.)

o    Show how physical activity can be FUN!  (For example,
dancing to MTV is fun.)

Channels for Communication

     The group identified the following channels for
communication: 

o    Print media

     --   Magazines
     --   Comics
     --   Fiction/books
     --   Clothing (for example, T-shirts)
     --   Posters

o    Electronic media

     --   Television (talk shows, entertainment,
advertisements)
     --   VCR (tapes to target high-risk groups)
     --   Music media (MTV, radio, cassettes, compact discs,
videos)

o    Face-to-face

     --   Peer groups 
     --   Role models (Empower teens to become teachers.)

o    Environmental 

     --   Schools
     --   Community organizations (churches, recreation
centers)
     --   Parents' worksites
     --   Kids' worksites
     --   Food processors/restaurants

o    Regulatory/intergovernmental communication/intra-agency
cooperation.

Issues for Research/Evaluation

     To improve and enhance the effectiveness of messages
and strategies, the group recommended the following research
and evaluations. 

o    Conduct formative evaluations of messages with teens.

o    Evaluate channels and credible sources.

o    Determine current knowledge base and whether the data
can help with health promotion efforts.

o    Evaluate whether the methods employed for changing
knowledge, attitudes, and behaviors actually produce the
desired outcomes.

o    Fund an ongoing evaluation.

Group members:  Cheryl Ritenbaugh, Ph.D., M.P.H. (group
facilitator); Kathy J. Bartlett, B.S., C.L.P.; William
Fabrey; Reva Frankle, M.S., R.D.; Robert Garrison, M.S.;
Regina Hildwine, M.A.; Sarah Kuester, M.S.; Pauline S.
Powers, M.D.; Thomas Robinson, M.D., M.P.H.; Elaine Stone,
Ph.D., M.P.H.; Anne Melly, M.S., R.D. (recorder).



SMALL GROUP REPORT:  ADULTS

Target Audience Overview

     Adults, for purposes of defining--and limiting--target
populations, can be considered in terms of several
subpopulations.  The group listed these subpopulations in
the following broad categories:

o    Age

     --   Young adults 18 to 29 years
     --   Middle adults 30 to 49 years
     --   Older adults 50 years and over

o    Education

     --   Less than high school
     --   High school
     --   College and postcollege

o    Socioeconomic status

     --   Low
     --   Medium
     --   High

o    Women

     --   Employed outside home
     --   At home

o    Men

     --   Single (does own cooking)
     --   Married (usually wife does cooking)

o    High risk:  Existing cardiovascular disease risk
factors versus no risk factors

o    Weight:  Currently obese versus not obese or overweight

     Two additional subpopulations were considered.  One was
parous versus nulliparous women.  The other was college-age
individuals, who were covered in the discussion of the small
group on adolescents but were discussed here in terms of
whether the college-age population should be a specific
target.  Some group members felt it was a low-risk
population; others saw it in terms of less-educated versus
college-educated women.  The group agreed that the obesity
problem is more common in the postcollege years. 

     Adult subpopulations listed but not discussed were
smokers (these need to deal with smoking cessation first),
minorities (these were addressed by the small group on
minority populations), and familial obesity (efforts here
will spin off from childhood strategies).  

Strategies Overview

     Before focusing on priority targets for the NHLBI
Obesity Education Initiative, the group addressed broad and
large-scale strategies (and messages) for the entire adult
population.  These strategies form the basis not only for
adult efforts but also for all OEI activities.

     Nutrition/Regulatory Strategies

     The group agreed that the emphasis should always be on
promoting healthy eating habits and patterns and that all
messages should be kept simple.  Broad nutrition regulatory
strategies for all audiences and populations should focus on
the following.

o    Placing understandable facts on labels.  Food labels
will make more sense and be more easily understood when
people learn what their allowance of total grams of fat per
day is.  Indicating percent calories from fat as well as
calories and grams of fat per serving should be mandatory.

o    Educating the public on how to interpret information. 
The NHLBI and other agencies should continue to take
responsibility for educating the public and increasing their
awareness of nutrition issues.

o    Emphasizing positive messages on what people can eat,
not only what they should avoid.  Simple, broad messages can
include "Eat more whole grains, more fruits, more
vegetables," "At least five servings per day of fruits and
vegetables," and "Follow food guide pyramid
recommendations."  Other appropriate messages are "Get fewer
than 30 percent of your calories from fat" and "Make low-fat
substitutions."

o    Stressing desirable versus undesirable foods. 
Suggesting food substitutions as dietitians do is helpful
("Eat fruit instead of pastry").  Similarly, suggesting
specific foods instead of nutrients is a useful, simple
strategy ("Use jam instead of butter, skim milk instead of
whole milk, chicken without skin").

o    Improving accuracy in advertising (using the Federal
Trade Commission's role and labeling to add pressure to do
so).

o    Encouraging fast food restaurants, other restaurants,
and supermarkets to offer lower- and low-fat food choices,
and provide labeling information about their products.

     Physical Activity Strategies

     The group agreed that to encourage the physical
activity necessary for all audiences and populations, the
messages should be kept simple and be attainable, as in, for
example, the following.

o    Take the stairs.  A good place for this message to the
public would be next to the elevator.

o    Walk 30 minutes a day (if feasible and safe).

o    Spend 30 minutes a day in any physical activity; that
is, "Invest in your health."  (In discussing specific
suggestions on how much time should be spent in actual
physical activity, one recommendation was 45 minutes a day. 
Most group members felt this was too much or too difficult. 
They felt strongly that if the goal seemed unattainable, no
effort would be made to reach it.)

o    Substitute physical activities for television watching.

Priority Targets

     The group selected as priority targets the following
adult subpopulations:

o    Women ages 18 to 65 of low socioeconomic status and
with low education, both at home and employed outside the
home.  The group saw a definite social class gradient in the
prevalence of obesity in women.  Thus, the consensus of the
group was to focus on the women at highest risk (with
different strategies needed for women at home versus those
employed outside the home).  Group members felt that the
broad population strategies would be both sufficient and
effective for women of medium to high socioeconomic status
and with more education because these women are not at high
risk for obesity.

o    Men ages 18 to 65.  The group targeted the total
population of men because group members could not justify
breaking men into socioeconomic and education
subpopulations.

     As it selected these priority targets, the group
discussed the need to make those in the target audiences
aware of what a healthy weight is.  The group then explored
the specific knowledge, attitudes, and behaviors in the
target populations that need to be accommodated if OEI
efforts are to be effective.

o    Knowledge.  Women in the target population are
generally limited in their knowledge of cardiovascular and
other diseases as hazards of obesity.  They also have
limited information about the importance of eating patterns
and physical activity.  Men are similarly limited in their
knowledge.

o    Attitudes.  Women in general are more concerned with
their appearance than men, with women in the target
population more accepting of higher degrees of body weight
than women in the higher socioeconomic and more educated
populations.  At-home women are less concerned with
appearance than employed women, but women employed outside
the home have time pressures affecting their eating patterns
(more eating out for themselves and their families), their
nutrition, and their physical activity.  In addition, women
employed outside the home usually have more social support
for weight control.  Men are more concerned with obesity as
a health issue rather than a cosmetic issue, although many
men think it is "natural" to gain weight as they get older.

o    Behaviors.  Women in the target population,
particularly employed women, have time constraints that
affect their physical activity and nutrition.  Men's alcohol
intake may affect their initiative for physical activity.

Content of Appropriate Messages

     The group agreed that appropriate messages must concern
healthy eating and other lifestyle behaviors--in particular,
emphasizing that weight gain, is an unrecognized health
hazard as people get older and that to prevent weight gain,
exercise should be increased and eating patterns modified. 
Furthermore, because eating disorders (such as bulimia and
anorexia nervosa) are usually not common in the target
populations, the messages must be linked to the health risks
of obesity.

     Specific messages for the target populations concerning
weight, eating patterns, and physical activity--all of which
should be kept simple--were discussed and developed by the
group as follows.

     Messages Concerning Weight

o    Don't gain weight/prevent weight gain.

o    Try to be weight stable.  Avoid major weight gains, and
aim for stability.

o    Link weight to healthy behaviors, physical activity,
and eating patterns.
     The group discussed the possible negative effects of
these weight messages, especially for young women.  However,
for the target populations, the issue of being too thin is
usually not a problem.  Furthermore, the message of body
shapes (apple versus pear and abdominal obesity), which
usually applies to people who are already obese--and which
have not been shown to be modifiable except through weight
change--need not be emphasized with this group.

     Messages Concerning Eating Patterns

o    Emphasize low-fat foods.

o    Stress serving size.  This is an important concept
because the five-fruits-and-vegetables-a-day campaign and
the daily food pyramid are overwhelming to many people
unless they know what a serving size is.  Thus, giving
examples of serving size is very important.

     Messages Concerning Physical Activity

o    Be more active.

o    Stress that every little bit counts.  It doesn't have
to be all at once.

o    Invest in your health.

     The group noted safety, cost, and lack of time as
barriers to physical activity for the lower socioeconomic
groups of the target populations.  If these barriers are not
broken down, most of those targeted will have an excuse not
to exercise, and all messages will be ineffective.  The
group noted that community centers have exercise facilities
and classes and that local malls have walking clubs. 
Walking with a partner, or walking a dog, can be a good
motivator for regular exercise.  Exercise programs are also
available on television, although such programs are often at
inconvenient times for the target populations.  Exercise
programs using VCRs may be a better tool for breaking
barriers, especially if a company can be found to underwrite
the cost of a VCR and videotapes.  An investment in home
exercise equipment (such as a stationary bike, treadmill, or
Stairmaster) can be cost-effective in the long-term.

Source Credibility

     The group discussed both credible and noncredible
sources of information.

     Credible Sources

     The group identified the following as credible sources
of information.

o    Physicians

o    Nurses

o    Clinical nutritionists and registered dietitians

o    Health care providers and health care organizations
(for example, health departments)

     The group noted that these professionals and
organizations need to provide for their clients a great deal
more information in the area of weight control.  A good
source of information might be industry, but the group felt
that further investigation was needed to ascertain the best
sources.  The group also noted that there is a lack of any
major organization (similar to, for example, the American
Diabetes Association) for the target populations, which
means that there is no advocacy group for obese people, and
no guidelines, campaigns, or policies specifically for them. 
Instead, obese men and women get pulled into other
groups--for example, cholesterol, diabetes, cancer,
arthritis.

     Noncredible Sources

     The group discussed how to deal with noncredible
sources, for example, some aspects of the weight loss
industry.  This is another area, the group felt, that needs
further investigation.  Data now indicate the
ineffectiveness of commercial weight loss programs; however,
data also indicate that weight control measures are not
generally seen as efficacious by credible sources.  One way
to address this dilemma may be to stress safety issues
related to diet programs and their nutrient content. 
Another may be to emphasize the data illustrating the poor
results from weight loss programs.  Yet another--which the
group acknowledged would benefit everyone--may be to stress
exercise and a healthy, low-fat diet, whatever your current
weight.  It may be possible to work with some weight loss
programs to produce positive messages on healthy eating and
physical activity.  Furthermore, if public education
programs stressed physical activity and healthy eating, and
continued to show the statistics on poor results from weight
loss programs, the weight loss industry might be influenced
to change its tactics.

     Some group members were not willing to endorse the
message that the effects of weight loss, even if temporary,
are bad and that participation in weight loss groups was
bad.  These members pointed out that often when obese people
go to their family physician for information on weight loss,
the physician will send them to a weight loss program for
help.  The group consensus was that no recommendations could
be made about entering weight loss programs, other than that
any such program should be chosen carefully because the
efficacy of special diet programs has not yet been
established.  The cost of these programs also may be
prohibitive for the target group. 

Motivational Strategies

     In addition to the broad, large-scale strategies
already proposed, the group identified the following
specific motivational strategies for the target populations.

o    Stress self-efficacy.

o    Emphasize more control over the environment.

o    Provide education on health hazards.

o    Stress healthy eating, and do not use the word "diet."

     In addition, the group suggested that more information
on motivational strategies needed to be obtained by using,
for example, focus groups.

     For Nontargeted Adults.  The group further suggested
strategies for nontargeted adult populations.

o    For young adult women in the childbearing years. 
Communicate messages through clinicians (e.g., obstetricians
and gynecologists) who come in contact with these women.

o    For young unmarried men.  Use general population
strategies about nutrition and healthy food preparation and
about eating out.

o    For high-risk groups.  Leave treatment strategy up to
the clinician.

o    For familial obesity.  Carry over strategies directed
to the obese children to the family through pediatricians
and family physicians.

     Evaluation.  The group stressed emphatically that
evaluation of strategies--as well as programs--is essential
for success in reducing the prevalence of obesity and in
controlling weight gain.

Audiences and Channels for Communication

     Identified by the group as appropriate audiences and
channels for communication were the following.

o    Worksite programs (for employed women and men)

o    Video programs, television exercise programs, and home
exercise equipment (for at-home women)

o    Food labels

o    Peer groups (e.g., men at barber shops and other
congregating areas)

o    Children (for women who can be reached through programs
aimed at their children--e.g., WIC)

o    Churches and religious groups (for men and women)

o    Public health programs (e.g., Head Start, health
departments, cooperative extension programs)

o    Media (e.g., television, radio, print)

o    Health care providers

o    Politicians (to be used with caution)

o    Mail (e.g., telephone bills, public utility bills).

Group members:  JoAnn Manson, M.D., Dr.P.H. (group
facilitator); Diane Bild, M.D., M.P.H.; Clarice Brown, M.S.;
Jeanne Goldberg, Ph.D., R.D.; Millicent Higgins, M.D.;
Robert Hoerr, M.D., Ph.D.; Robert Jeffery, Ph.D.; Hal Seim,
M.D., M.P.H.; Anne Shaw, Ph.D.; Jeffery Sobal, Ph.D.,
M.P.H.; David Williamson, Ph.D.; Mary Winston, Ed.D., R.D.;
Joanne M. Gallivan, M.S., R.D., L.D. (recorder).

SMALL GROUP REPORT:  OLDER ADULTS

Target Audience Overview

     Older adults, for purposes of defining target
audiences, need to be considered in terms of the various
gradations of aging.  The group listed the overall
characteristics of the population of older adults as
including the following.

o    Age 65 years and older

o    Growing population 

o    Preponderance of women

o    Broad range of educational levels and socioeconomic
status

o    More leisure time

o    Desire to remain independent

     In addition, the population of older adults generally
have decreased mobility, hearing, and vision as well as
higher rates of chronic disease, malnutrition, social
isolation, and Government assistance (e.g., Medicare and
meal programs).

     Older adults' attitudes toward weight (which apply to
some but not all subpopulations of older adults) include the
following.

o    Less concern with overweight and about weight in
general as it stabilizes or declines

o    More concern about undesired weight loss, particularly
in advanced ages

o    Greater concern about health and less concern about
appearance

o    Perception of healthy weight as a means to reduce
chronic disease

o    A link between weight and mobility and independence

     Behaviors affecting weight (which also apply to some
but not all subpopulations of older adults) relate to the
following.

o    Activity level (choice of leisure activity, degree of
mobility)

o    Caloric intake (cooking style, food selection).  Older
adults who are in nursing homes or who participate in senior
meal programs have no control over either food selection or
preparation.  Other older adults have inadequate calorie
intakes, and many eat alone.

o    Smoking

o    Alcohol

o    Drug use (both prescription and over the counter)

o    Forgetfulness

o    Depression

o    Degree of socialization

     The amount of knowledge older adults have about weight
affects their attitudes and behavior.  The group felt more
information was needed in this area.  The group felt that
cultural influences affect older adults' knowledge about
weight.  They also think older adults tend to feel that they
are not getting fatter if their weight is stable. 

     Other factors also affect the weight and weight loss of
older adults.  For example, most older adults have a greater
fear of injury and more difficulty exercising.  They are
also more susceptible to fad diets and gimmicks.  As their
ability and inclination to exercise decrease, they must put
more emphasis on caloric restriction.

     Physical activity for older adults is very important;
it helps prevent the loss of lean body mass, promote
mobilization and the redistribution of body fat, preserve
strength and endurance, and maintain bone density.

Priority Target

     The group saw the entire population of older adults as
the priority target.

Content of Appropriate Messages

     The group developed the following general messages for
older adults. 

o    Gradual change will help make lasting change.

o    Each individual has the ability to improve his or her
health.

o    Physical activity and a healthy diet are necessary for
good health.

     The group also developed these specific messages.

o    Body composition is more important than weight.

o    Increased physical activity improves fitness and
reduces cardiovascular disease.

o    Eating a healthy diet is beneficial.  (How to implement
a healthy diet must also be part of the message.)

o    Retirement is not a time to be sedentary.

     The group also decided to develop a message about fat
distribution because older adults are at high risk for
cardiovascular disease.  (Physicians must be trained to
recognize the importance of fat distribution in adults,
particularly older adults.)

Source Credibility

     The group identified the following as credible sources
of information on weight for older adults.

o    Peers

o    Medical and health professionals

o    Community opinion leaders (e.g., directors of nursing
homes, members of social clubs)

o    Television, newspapers, and magazines (including
advertising)

o    Supermarket promotions and food labels

o    Government agencies

o    Medicare

o    Senior centers

o    Adult day care organizations

o    Churches

     The group needs more information before it can
determine which sources of information most affect behavior.

Motivational Strategies

     The group identified several possible motivational
strategies. 

o    Emphasize fitness and a healthy diet.

o    Provide positive reinforcement to older adults' efforts
to maintain their health, independence and mobility, and
dignity.

o    Reflect cultural differences, and be culturally
sensitive.

o    Address climatic and environmental concerns.

o    Address cost issues.

o    Emphasize possible pain reduction.

o    Recognize fear of ill health and death.

o    Use models that encourage participation.

o    Use models that are appropriate for the age group.

o    Mobilize the community through such programs as Planned
Approach To Community Health (PATCH).

o    Create messages for specific subpopulations.

     The group felt that prevention messages are not
appropriate for this audience because it is usually too late
for prevention.  The group agreed that treating everyone the
same is not a successful motivational method. 

Channels for Communication

     The group identified the following appropriate channels
for communication.

o    Advocacy groups (e.g., the American Association of
Retired Persons)

o    Government, military, and professional retirement
organizations and facilities

o    Medicare and Social Security

o    Insurance companies

o    Public utilities

o    Direct mail 

o    Volunteer agencies and organizations

o    Health fairs

o    Health professionals

o    Waiting rooms of hospitals and physicians' offices

o    800 and 900 telephone numbers

o    Supermarkets

o    Social gatherings and clubs

o    Private homes and retirement communities

      Among the effective tools the group identified for
these channels to use in delivering messages were
television, radio, large-print reading materials, and
one-on-one
contact.

Group members:  Peter D. Wood, D.Sc., Ph.D. (group
facilitator); Joan Blair, R.N., M.P.H.; Susan T. Borra,
R.D.; Carolyn Clifford, Ph.D.; Eileen Conover; Jeanne
Creech, Ph.D.; Michael J. Horan, M.D., Sc.M.; Frederick N.
Hyman, D.D.S., M.P.H.; Arthur S. Leon, M.D.; Marilyn G.
Stephenson, M.S., R.D.; Maureen N. Harris, M.S., R.D.
(recorder).


SMALL GROUP REPORT:  MINORITY POPULATIONS

Target Audience Overview

     The four major minority populations in the United
States--African Americans, Hispanic Americans, Asians and
Pacific Islanders, and Native Americans--are the fastest
growing segments in the total U.S. population.  They also
tend to exhibit the following demographic characteristics.

o    High poverty rates

o    High high-school dropout rates

o    High teenage pregnancy and single parenthood rates
(mostly women)

o    Different distributions by states and clusters within
areas

o    Limited access to health care and food

o    High levels of risk factors and high incidence of
disease

o    Variant health knowledge and practices, including:

     --   Many misconceptions
     --   Use of traditional/folk medicine and lore
     --   General concerns about health, with a moderate to
high awareness of diabetes and high blood pressure but a
relative lack of awareness about weight
     --   Associations between weight and family income and
between thinness and illness
     --   Different orientations to physical activity, with
such activity not the norm, not valued, and mostly
associated with the white population and affluence
     --   More traditional and separate gender roles
     --   A spiritual meaning attached to food
     --   Hospitality revolving around food
     --   Single parents doing less cooking 
     --   Heavy reliance on fast food restaurants 

o    An untapped market for products associated with
increasing the risk of disease

     Some of these characteristics (e.g., lower income and
lower education level) are related to weight loss practices. 
According to the 1990 National Health Interview Survey
(NHIS) of the National Center for Health Statistics,
overweight individuals least likely to be dieting were those
with less than 12 years of education and those with family
incomes of less than $10,000 (National Center for Health
Statistics, 1993).  The U.S. Department of Agriculture's
(USDA) 1989 Diet and Health Knowledge Survey (unpublished
data) found that among female main meal planners/preparers,
73 percent of whites and 76 percent of African Americans
considered maintaining a desirable body weight of high
importance.

     African Americans

     Data reported by Bennett (1991) from the Centers for
Disease Control's Behavioral Risk Factor Surveillance System
(BRFSS) (1985-88) show that the prevalence of overweight for
African-American women is twice that for white women.*  The
prevalence of overweight is similar for African-American and
white men, except at older ages when overweight is more
prevalent for African-American men 65 years and older.

     According to the BRFSS data, weight loss practices
among white and African-American women are similar. 
Increasing physical activity and eating fewer calories are
the weight loss practices most frequently reported by about
a third of the women of both races.  However, research has
shown that African-American women do not lose weight as
easily as white women (Kumanyika et al., 1992). 

     Data from NHANES II indicate that obesity (defined as
triceps skinfolds greater than or equal to the 85th
percentile of children of the same age and sex) among
African-American boys remains substantially less prevalent
than among white boys (Gortmaker et al., 1987).  For boys 6
to 11 years old, 16.6 percent of African-American boys were
overweight versus 31.5 percent of white boys.  For 12- to
17-year-olds, 12.7 percent of African-American boys were
overweight versus 19.5 percent of white boys.  The
prevalence of obesity among African-American girls is quite
similar to the rate for white girls.  For girls ages 6 to
11, 20.9 percent of African-American girls are obese versus
26.0 percent of white girls.  For 12- to 17-year olds, 25.1
percent of African-American girls are obese versus 25.6
percent of white girls.  African-American adolescent girls
are dieting and are preoccupied with weight, but not as much
as white adolescent girls (Serdula et al., 1993). 

     According to the Food and Drug Administration's (FDA)
1992 Weight Loss Practices Survey (Levy and Heaton, 1993),
adults over 18 years of age in African-American households
who were trying to lose weight fasted and used diet pills,
laxatives, and fiber supplements more often than their white
counterparts, and they were also more overweight.  In a
National Institutes of Health study on binge eating
disorders by Yanovski and colleagues (1992), binging was
equally high among African-American and white women. 
African-American adolescent girls do not use smoking as a
means of weight control, but a substantial number do binge,
fast, and purge.

     For most African Americans, food is more than
nutrients; it is the focal point of family gatherings.  It
eases stress and is associated with prosperity.  The feast
(at the beginning of the month when more money is available)
or famine (at the end of the month when resources dwindle)
cycle often dictates the behavior of low-income African
Americans.

     African Americans--except for males up to age
25--generally are not physically active.  Some of the
reasons include lack of time (particularly in single-
parent families), concern for safety while exercising, 
and the cultural belief that exercise is selfish because
it takes time away from family responsibilities.  
However, according to the FDA's 1992 Weight Loss 
Practice Survey, African Americans who are dieting do
exercise as much as whites, and for them the most common
form of exercise is walking.

     Hispanic Americans

     Overweight is common among Hispanic Americans. 
According to the Hispanic Health and Nutrition Examination
Survey (HHANES), 29.7 percent of Hispanic men and 39.1
percent of Hispanic women are overweight (National Center
for Health Statistics, 1989).*

     In the Hispanic culture, being heavy is associated with
being healthy, whereas thinness is associated with illness. 
A chubby baby, for example, is viewed as a healthy baby.  In
addition, many traditional songs link heaviness with health. 
For Hispanic women, weight traditionally has been linked
with sexuality and marriage; before marriage, Hispanic women
are thin.  The group suggested that Hispanic women gain
weight after marriage as a security blanket to avoid
aggressive men, which in turn makes husbands less jealous. 
This pattern is thought to be slowly changing.

     Asians and Pacific Islanders

     Asians and Pacific Islanders are not represented in
most national health and nutrition surveys; therefore, there
is a paucity of data on the overall prevalence of obesity
for this group.  Data on overweight among Japanese and
Filipinos come from the 1986 BRFSS in the State of Hawaii
(Hawaii State Department of Health, 1986).  Based on
self-reported data, the prevalence of overweight is lower
among Japanese and Filipinos (13.0 percent and 8.3 percent,
respectively) than among whites and other minorities.

     The group felt that Asian-American children generally
are not obese, although they have a higher body weight than
those from previous generations and remain small in stature. 
It was felt that Asian-American children want to be like
Americans and eat at fast food restaurants and participate
in school lunch programs, but their parents tend to retain
their traditional diets.  One reason is that they may not
always have the knowledge or resources to prepare foods
common to the American diet.  Another is that language can
be a barrier, particularly for some recent immigrants. Yet
another reason is that many times food combinations eaten in
the typical American diet are not acceptable in terms of
traditional hot and cold food practices.  However,
Asian-American parents want their children to be strong 
and taller in stature like Americans.  Physical activity
also is counter to the accepted Asian-American culture.

     Native Hawaiians, on the other hand, suffer from
disproportionately high rates of obesity (Aluli, 1991).  In
a 1985 cardiovascular risk factor survey of Native
Hawaiians, 65.5 percent of males and 62.8 percent of females
in the study populations were classsified as obese (Aluli,
1991).  Using the body mass index measures employed by the
NHANES II, the overall obesity rate was 63.6 percent in this
Native Hawaiian group, with severe obesity occurring in 46.4
percent of males and 33.9 percent of females (Aluli, 1991). 
Overweight occurred earliest in males:  79.2 percent of
those ages 25 to 34 were overweight.  Obesity was greatest
in older women, with 83.9 percent of these 45- to
54-year-olds overweight (Aluli, 1991; Curb et al., 1991). 
The self-reported data of the 1989 Hawaii BRFSS show 
Native Hawaiians with the highest percentage of obesity at
40.2 percent, compared with the overall State prevalence
rate of 20.9 percent (Hawaii State Department of Health,
1991).

     The current situation represents a drastic change from
traditional times, probably brought about by the complete
westernization of the diet and lifestyles of Native
Hawaiians today.  Obesity was not a problem in traditional
times.  Native Hawaiian men were described by the first
visitors to the Islands as "tall, well made, with finely
drawn muscle," "a joy to behold" (Mortelier, no date), and
"above middle size, strong, muscular, well made of dark
copper colour . . . [who] walk gracefully, run nimble, and
are capable of bearing great fatigue" (Beaglehole, 1967). 
Older men were reported to be heavier but tall enough to
carry their weight (Beaglehole, 1967).

     All available obesity data on Native Hawaiians are
those gathered while researching other health conditions in
this Native American population.  Although existing data
sets often are not comparable because of different research
methodologies and measurement, recent data consistently
corroborate higher rates of obesity and disproportionately
higher rates of age-adjusted mortality for chronic diseases
compared with the U.S. all-races rates of obesity (U.S.
Congress, 1987). Directed research is essential to elucidate
the role of obesity as a risk factor and to ascertain means
to reduce these health disparities.

     Native Americans

     Native Americans also are not represented in most
national health and nutrition surveys, and as a result,
there is a paucity of data on the overall prevalence of
obesity in this group.  However, using several sources of
existing data, Broussard and colleagues (1991) have
estimated the prevalence of overweight and obesity in
American Indians and Alaska Natives.  Based on self-reported
data, the prevalence of obesity was 33.7 percent in adult
males and 40.3 percent in adult females.  These data also
suggest a secular increase in pediatric obesity in the
Native American population.

     Limited resources, access to grocery stores, choices of
foods in available stores, and refrigeration result in
dependence on commodity foods.  These foods are generally
high in fat, saturated fat, and calories.  Isolation, a high
unemployment rate, extreme weather conditions, and a lack of
recreational facilities all contribute to television being
used as a means of entertainment and occupying idle time. 
Binge drinking presents health and safety problems. 
Depression and fatalism concerning predispositions to
developing diabetes and alcoholism are common.  Diabetes
rates for Native Americans are higher than for other ethnic
groups (Gohdes et al., 1993).  Furthermore, few Native
American health professionals are available to help address
these and other problems.

     Data are not available on the weight loss practices of
the adult Native American population.  However, in
adolescents in both urban and rural environments, weight
loss behaviors associated with eating disorders such as
frequent dieting, food binging, self-induced purging, and
use of laxatives and diet pills were reported (Smith and
Krejci, 1991).  Differences between rural and urban Native
Americans in socioeconomic status and access to health care
need further study to design appropriate messages.

Priority Targets

     The group suggested that the overall priority for the
NHLBI Obesity Education Initiative should be to target
African-American women ages 20 to 25 because this population
has a particularly high prevalence of overweight. 
Adolescent African-American girls also should be a priority
target--in terms of primary prevention--because excessive
weight for this population begins at puberty.  Other primary
prevention target populations include Native Americans,
Asian Americans, Native Hawaiians, and Hispanic Americans,
the youngest and fastest growing segments of the U.S.
population.  Because of the traditional gender roles and the
strong family units in minority cultures, women should be
the target for messages on healthy eating and men for
messages on physical activity.  The overall goal should be
to give these populations a sense of empowerment and to
increase their self-esteem. 

Content of Appropriate Messages

     The group felt that more research needs to be done on
what the most appropriate messages are for each minority
because there needs to be an understanding of the underlying
reasons by population group and by age.  It is recommended
that established local networks within each minority
population be utilized to help in message development.  The
group felt that it was essential to segment the populations
according to country of origin, how long they have been in
the United States, and their degree of acculturation.  The
group also recommended that efforts begin with a massive
campaign to raise awareness, followed by targeting
individual lifestyles for change.  Most likely the focus of
the different groups could be combined because they share
similar characteristics.

     In developing messages for minority populations, it is
important to note that the traditional methods of treatment
have failed, and as a result, most people feel cheated.  The
group felt that quality of life, including how to live
better and help each other, and family and community values
should be emphasized.  An essential message to convey is
that overweight is not a sign of good living; the notion of
weight loss for "feeling good" versus "looking good" should
be emphasized.  As already noted, for adolescent girls and
women, self-esteem and empowerment should be stressed.  All
messages should be simple, easy to understand, and tested
with focus groups for relevance.

     Appropriate to include in messages are the following.

o    Recognition of traditional culture, particularly those
cultural elements that can enhance the message

o    Economic and diet issues

     --   Food as security
     --   Food as fitting in
     --   Feast or famine
     --   Food and its role in celebrations, rewards,
happiness, spirituality
     --   Substitution versus dramatic changes

o    Physical activity promoted through lifestyle changes
that have no cost ("burn it off") in relation to gender,
role models, real activities

o    Attractiveness

o    Fun

o    Real-world skills (e.g., how to select healthy food
from a fast food restaurant)

o    Choice

o    Incorporation into family activities throughout the
life cycle, especially preparing and buying foods

     For African Americans

     Messages for African Americans should emphasize
lifestyle changes and physical activity to lower risk
factors instead of weight loss.  Messages should also be
family- and church-oriented.  They should emphasize small,
appealing changes in diet (substitutions versus large
changes in food selection) and physical activity.  Messages
to adolescents should include the ideas that health is
attractive and gives you strength, that eating gives you
energy and can be fun, and that attractiveness gives you
self-esteem.  Education and training on budgeting and
planning need to be included to break the cycle of feast or
famine.

     For Hispanic Americans

     Family and friends are very important to the
Hispanic-American
population.  Messages should focus on how the
desired behavior will empower and help the family, not just
one individual.  Messages should be directed to women about
making dietary substitutions versus trying something new. 
Fat, saturated fat, and calorie levels, for example, can be
reduced easily by making the small change of substituting
yogurt for sour cream in traditional recipes.  The
relationship between exercise and health also should be
emphasized.  Messages linking weight with mortality may help
change perceptions about weight.  Short messages with
visuals should be employed.

     For Asians and Pacific Islanders

     Asians and Pacific Islanders should be targeted for a
primary prevention message because overweight is not a major
problem for most of this population.  However, it could
become a problem in the future if appropriate steps to
prevention are not taken.  Native Hawaiians should be
encouraged to return to the "body image" of the traditional
Hawaiian.  (Obesity was not a problem in traditional times.)

     For Native Americans

     Messages for Native Americans should emphasize
lifestyle changes and physical activity to lower risk
factors instead of weight loss.  Messages need to convey
that healthy eating is neither expensive nor a drastic
change from current habits.  Low-fat substitutions for
high-fat
foods, reductions in quantity, and changes in
preparation should be emphasized while maintaining the
notion that eating is fun and food tastes good.  Education
on budgeting and planning are important.  Community
involvement is essential to successful messages.  Community
health representatives should be used to disseminate
materials.  Native Americans are ultimately responsible for
their own health and should be involved in determining the
message and messenger.

Source Credibility

     Minority populations receive information from family
(including extended family) and friends, physicians and
pharmacists, community health workers (peers and local
organizations), local networks (lay and professional
education), churches, and the media (local community
newspapers, magazines, and television).  For adolescents,
television is particularly popular.  However, all cultures
can be reached using television if populations are
segmented.  Specifically, credible sources for each
population are listed below.

o    For African Americans:  Physicians, churches,
magazines, sports figures, celebrities, musicians
(especially female rappers to young women), extended
families and friends (especially to young women), and
pharmacists

o    For Hispanic Americans:  Family, friends, physicians,
churches, and the media

o    For Asians and Pacific Islanders:  Churches, local
community papers, ethnic grocery stores, and the media

o    For Native Americans:  Health clinics, tribal leaders,
powwows, traditional healers, friends, community health
representatives, and WIC programs

Motivational Strategies

     Strategies for motivating the various minority groups
to act on information should incorporate and emphasize the
following.

o    Family

o    Community contribution

o    Self-enhancement/benefits

o    Positive reinforcement

o    Empowerment

o    Retention of ties to traditional culture

o    Fun

o    Skill training

o    Environmental changes

     --   Cues to physical activity
     --   Improving access--community/business
     --   School lunch, commodities
     --   Grocery stores, restaurants (especially fast food)
     --   Dance, music

     For African Americans

     Strategies for African Americans should address the
lack of access to and high cost of groceries in the inner
cities.  Primary prevention efforts should promote healthy
eating patterns, with "fun" messages coming from peers,
pharmacists, church leaders, senior centers, television, and
music.  To promote physical activity and strength for boys,
participating in sports without using steroids should be
encouraged.

     For Hispanic Americans

     All strategies for Hispanic Americans should focus on
the family because of its strong influence in this culture.

     For Native Americans

     Intervention strategies for Native Americans should
emphasize healthful eating and physical activity and allow
them to make their own choices to give them a sense of
self-empowerment.  Stress should be on integrating
traditional
ways, such as running, dancing, and race walking for
physical and spiritual fitness.  Messages on physical
fitness should emphasize strength because the Native
American's orientation is to what can be done for the next
generation and the good of the tribe versus oneself. 
Messages also must consider religious and spiritual beliefs.

     Work to initiate any type of change must simultaneously
address leaders of the tribal government who can support
individuals' efforts to change.  Efforts should include
changing the composition of the commodity foods provided and
working with the tribal community to change the foods
available in the grocery stores.  Prevention efforts must
begin early--including prenatal education--and school health
initiatives must begin before high school because the high
school dropout rate is high.

     Awareness of obesity's association with diabetes and
awareness of diabetes in general have been enhanced by major
health initiatives by the Federal Government.  These efforts
should be expanded and enhanced.  Efforts also should be
made to link obesity to diabetes, heart disease, and other
obesity-related chronic diseases.

     To develop a strategy on physical activity, a needs
assessment in various communities may be worthwhile to find
out from the community what physical activities are
suitable.  Messages need to include the traditional Native
American symbols of heroism, such as runners and dancers.

Channels for Communication

     Messages to minority populations should generally be
targeted to the following.

o    Immediate and extended family members, especially older
family members (such as the aunt or grandmother) to target
to younger members

o    Physicians

o    Community health workers

o    Local organizations

o    Local community newspapers and magazines

o    Established professional and educational networks

o    Mass media

o    Fast food restaurants serving healthy foods that taste
good

     For African Americans

     Messages for African Americans should be directed
primarily through physicians and magazines.  Mass media
messages should be specifically targeted through sports
figures and rap singers, especially for adolescents and
young adults.  Connections should be made with dancing and
music.  Interpersonally, information channels should include
peers and allied health professionals such as pharmacists,
community and lay health workers, senior citizen centers,
fraternal organizations, and other African-American
networks.  Although many African Americans do depend on
their physicians, not enough training on weight control is
provided in medical school.  Health messages printed on hand
fans disseminated in churches have been used effectively in
some communities to increase awareness.

     For Hispanic Americans

     Radio, followed by television, is the electronic medium
used most often by Hispanic Americans.  Print materials are
not used as widely; when they are developed, they should be
bilingual.  Health messages on calendars that include a
picture of the homeland have been used in some community
settings.  Ethnic grocery stores are places where Hispanics
seek out information.  Messages also may be channeled
effectively to families through a facilitator from their
community.

     For Native Americans

     Efforts need to be channeled through the established
leaders of the tribal governments such as community health
representatives and nutrition aides.  Other channels for
Native Americans include reservation trading posts and
grocery stores, local cable television, and local
newspapers.

     For Asians and Pacific Islanders

     Print material is very important to the Asian-American
community and should be multilingual.  Some segments of this
population do not have a written language; therefore,
videotapes in their native language are appropriate.  Other
channels can include local newspapers and health messages
printed on fly swatters or calendars with a picture of the
specific population's homeland.

Group members:  Patricia J. Elmer, Ph.D., R.D. (group
facilitator); Tanya Agurs, M.S., R.D.; Matilde Alvarado,
R.N., M.S.N.; Richard R. Fabsitz, M.A.; Betty Lee Hawks,
M.A.; Dana Robin Hill, Ph.D.; Alan Heaton, Ph.D.; Gloria
Nichols, Pharm.B.S., M.Ed.; Diana Schmidt, M.P.H., R.D.;
Bonnie Spring, Ph.D.; Karen S. Strauss, M.S., R.D.; Julie
Will, Ph.D., M.P.H.; Susan Yanovski, M.D.; Eileen P. Newman,
M.S., R.D. (recorder).

These issues related to obesity and minority populations
also were raised for discussion at the February 1993 meeting
of the NHLBI Ad Hoc Committee on Minority Populations.  The
comments by the committee have been incorporated in this
document, and their input is greatly appreciated.


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