Making America fit and trim--steps big and small.

By all measures, America’s weight problem has grown to epidemic proportions. Only tobacco poses an equally large, potentially reversible, long-term threat to our country’s health and well-being. Fortunately, this national tragedy is beginning to receive the attention it deserves, and Americans are confronting the truth—that our expanding waistlines are creating a public health crisis that, if recent estimates prove accurate, threatens to erode hard-won gains in life expectancy and health-related quality of life. The trends are astounding and truly alarming, particularly in what they portend about the health of our youngest generations. Since 1980 the prevalence of overweight has doubled for children and tripled for adolescents.1 As with tobacco use, much of the obesity problem is rooted in childhood and adolescence. But we know far less about the mortality and morbidity risks from overnutrition and inactivity than we do about tobacco, and even less about effective long-term interventions. Three years after publication of The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity,2 important steps, big and small, are being taken. The Department of Health and Human Services has made obesity prevention a top public health priority, and the Centers for Disease Control and Prevention (CDC) is taking the lead on many of the department’s current initiatives and programs. These programs include communication and education efforts; interventions in nutrition, physical activity, and fitness; disease surveillance; research; clinical preventive services and therapeutics; and policy and Web-based tools. They target populations at all life stages, including infants, breastfeeding mothers, and children and adolescents. The centerpiece of this effort is the “Steps to a HealthierUS” initiative launched earlier this year by Secretary of Health Tommy Thompson. As an important part of this initiative, the CDC has launched the new Steps to a HealthierUS cooperative agreement program, for which almost $44 million was appropriated in fiscal year 2004. This 5-year program funds communities to implement coordinated, comprehensive, and effective community-, school-, and workplace-based chronic disease prevention and control focused on obesity, diabetes, and asthma. Many more steps must be taken. As the problems of overweight and obesity have grown, so have the needs for new action and more research to deal with the complex set of challenges they pose. Sadly, prevention and health protection activities account for far less than 5% of the nation’s spending on health services. Likewise, our nation’s investment in public health research to define effective intervention strategies and the cost-effective means to disseminate them is a minuscule fraction of what is needed. The need for collaboration with the private sector has never been greater. Taking the lead here, the CDC recently announced the new $30 million Health Protection Research Initiative that will focus on producing the evidence to inform employers about cost-effective choices in wellness programs to benefit their employees. This effort includes funds to establish the new academic Center for Excellence in Health Promotion Economics, which will apply economic theory and methods to improve the effectiveness of health protection programs in priority areas, including the workplace. Concerned corporations have undertaken similar efforts, and the developing evidence base will give employees and employers confidence that health protection investments in the workplace will pay off. Undoubtedly, childhood presents an important opportunity to slow the US obesity epidemic. By devoting a special issue to obesity and youth, the Journal has taken an important step in this direction. Changes in diet quality among preschoolers, the relationship between urban sprawl and obesity, environmental interventions to promote healthier food choices in schools—these topics, addressed in this issue, and many more, must be addressed if we want to close the research gap. Although excess weight gain ultimately is caused by a chronic imbalance between energy intake and energy expenditure, the specific behaviors that have shifted the energy balance for children are not as well known as they should be. Only a very limited number of studies have investigated strategies to prevent excess weight gain among children.3 Since we know that childhood obesity is a strong determinant of obesity in adulthood, early childhood is likely to be an important period for intervention. For example, a recent analysis of the CDC’s Pediatric Nutrition Surveillance System data found that overweight during infancy persists through the preschool years.4 CDC research also shows that prolonged breastfeeding is associated with a reduced risk of overweight among non-Hispanic White children at 4 years of age.5 We need to move faster in designing and implementing programs that work with children and parents to prevent and treat obesity. Based on epidemiological evidence and plausible mechanisms, these strategies include promoting breastfeeding, limiting television viewing, and encouraging physical activity. Other promising strategies include increasing fruit and vegetable intake, controlling portion size, and limiting soft drink consumption. Each intervention alone is only a small step in what will have to become a more comprehensive national effort. The CDC recognizes the critical role schools play in encouraging healthy behaviors in youth. With 53 million young people attending nearly 119 000 schools across the nation, educators are vital to reversing the epidemic of overweight and obesity among children. The CDC is working with some states to conduct interventions geared toward preschool- and school-aged children. These interventions use a range of strategies to improve diet and physical activity levels of young people, such as revising school curricula to include messages about diet, physical activity, and television viewing; altering school environments to provide more healthful food and beverage options; promoting walking to school; and providing after-school programs that promote physical activity and a healthy diet. Maine, for example, prohibits the sale of sodas and candy during the school day. North Carolina requires every school district to establish a school health advisory council and prohibits the removal of recess and physical activity as a form of punishment. School-based prevention measures not only make sense, they can be cost-effective as well. The CDC recently published an economic analysis of Planet Health, a school-based intervention designed to reduce obesity in middle school. The program focuses on decreasing television viewing, decreasing consumption of high-fat foods, increasing fruit and vegetable intake, and increasing moderate and vigorous physical activity. At an intervention cost of $33 600 for 1200 students, the study estimated that the program would prevent about 6 female students from becoming overweight adults and would save society a total of $16 000 in medical costs and approximately $25 000 in lost-productivity costs.6 The media have an important role to play in promoting healthy behaviors. Using social marketing strategies, the CDC’s VERB campaign, an ad promotion campaign designed to encourage physical activity, developed a “for kids, by kids” brand that has proven successful in reaching “tweens” (aged 9–13 years) and promoting social norms that support physical activity and fitness. Through an integrated marketing strategy using paid media, physical activity is presented as an opportunity to be active, play, and have fun. Partnerships with athletes, celebrities, recognized kids’ brands, and national sports leagues contribute to VERB’s “cool” image. Results from the 2003 Youth Risk Behavior Survey show some encouraging progress in promoting healthy behaviors that influence overweight and obesity.7 The dramatic decline in daily participation in physical education classes that took place in the early 1990s (from 41.6% in 1991 to 25.4% in 1995) has been stopped; 28.4% of high school students participated in daily physical education classes in 2003. The percentage of high school students who reported watching television 3 or more hours per day on an average school day has declined significantly, from 42.8% in 1999 to 38.2% in 2003. Still, physical activity and eating habits show much room for improvement. In 2003, 1 out of 3 high school students (37.4%) had not participated in sufficient vigorous physical activity during the 7 days preceding the survey, and 44.3% were not enrolled in a physical education class at all. Fewer than 1 out of 4 students (22%) reported that they had eaten fruits and vegetables 5 or more times per day. These data from our nation’s school health report card help us see where our efforts are succeeding and the hard work that lies ahead. As the CDC implements its Futures Initiative, with its life-stages framework and its customer-oriented focus, we know we will make an even greater impact on this epidemic. But this war at the waistline must engage everyone—families in their homes, medical providers in their clinics, teachers in their schools, employers in their workplaces, and scientists in their laboratories. Through better science, better communication, and better collaboration, we can and will get ourselves and our children back on the road to better health.