1. Obesity Prevention and Control Programs in the United States William H. Dietz, M.D., Ph.D. Division of Nutrition and Physical Activity Centers for Disease Control and Prevention

2. International Conference for cardio/cerebrovascular disease Overview of Weight Control Efforts Problem Definition Assessment Prevalence Disease burden Strategy Development Social Ecologic Model Community Guide Translation Implementation State Programs, Steps Policy/environmental Interventions Media Evaluation

3. International Conference for cardio/cerebrovascular disease Source: Behavioral Risk Factor Surveillance System, CDC. 19961991 2004 No Data<10%10%-14%15%-19%20%-24%  25% Obesity Trends* Among U.S. Adults 1991, 1996, 2004

4. International Conference for cardio/cerebrovascular disease Source: JAMA, Oct. 9, 2002, Vol. 288, No. 14:1731 and Pediatures 1998; 101:497 Overweight Prevalence by Race/Ethnicity for Boys Aged 6 - 11 Years Percentage 0 5 10 15 20 25 30 Non-Hispanic White Non-Hispanic Black Mexican American NHANES III 1988-1994 NHANES 1999-2000

5. International Conference for cardio/cerebrovascular disease Percentage Source: JAMA, Oct. 9, 2002, Vol. 288, No. 14:1731 and Pediatures 1998; 101:497 Overweight Prevalence by Race/Ethnicity for Girls Aged 6 - 11 Years 0 5 10 15 20 25 Non-Hispanic White Non-Hispanic Black Mexican American NHANES III 1988-1994 NHANES 1999-2000

6. International Conference for cardio/cerebrovascular disease Impact of Childhood Overweight (BMI > 95th percentile) on Adult Obesity (BMI > 30) 4.9 BMI unit difference in severity Onset < 8y more severely obese as adults ( BMI = 41.7 vs 34.0) CVD risk factors reflect adult BMI 25% obese adults were overweight children Freedman et al, Pediatrics 2001; 108: 712

7. International Conference for cardio/cerebrovascular disease CDC’s Priorities to Control the Obesity Epidemic Prevent excessive weight gain in children and adolescents Weight loss and maintenance of weight after weight loss in adults Eliminate disparities in obesity and its complications

9. International Conference for cardio/cerebrovascular disease % Total Change in Spending by Top 10 Conditions 1987-2000 Heart disease Pulmonary conditions Mental disorders Cancer Hypertension Trauma Cerebrovascular disease Arthritis Diabetes Back problems 30% 16% Thorpe et al. Health Affairs 2004; W4-437

10. International Conference for cardio/cerebrovascular disease Costs of Obesity Costs of illness Costs of absence from work Costs of reduced productivity Costs of injuries Costs of disability

11. International Conference for cardio/cerebrovascular disease Overview of Weight Control Efforts Problem Definition Assessment Prevalence Disease burden Strategy Development Social Ecologic Model Community Guide Translation Implementation State Programs, Steps Policy/environmental Interventions Media Evaluation

12. International Conference for cardio/cerebrovascular disease A Public Health Framework to Prevent and Control Overweight and Obesity Energy Intake Energy Expenditure Energy Balance Prevention of Overweight and Obesity Among Children, Adolescents, and Adults Note: Adapted from “Preventing Childhood Obesity.” Institute of Medicine, 2005. Individual Factors Behavioral Settings Social Norms and Values  Home and Family  School  Community  Work Site  Healthcare  Genetics  Psychosocial  Other Personal Factors  Food and Beverage Industry  Agriculture  Education  Media  Government  Public Health Systems  Healthcare Industry  Business and Workers  Land Use and Transportation  Leisure and Recreation  Community- and Faith-based Organizations  Foundations and Other Funders Food and Beverage Intake Physical Activity Sectors of Influence

13. International Conference for cardio/cerebrovascular disease Principal Strategies Physical activity Reduced television time Reduced soft drink consumption Breastfeeding Fruit and vegetable consumption Control of portion size

14. International Conference for cardio/cerebrovascular disease Role of Physical Activity in Weight Control Dose to prevent obesity unknown Dose to maintain weight after loss ~ 1 hr/d Relatively modest impact on weight loss Reduces obesity associated comorbidities

15. International Conference for cardio/cerebrovascular disease Principal Strategies Physical activity Reduced television time Reduced soft drink consumption Breastfeeding Fruit and vegetable consumption Control of portion size

16. International Conference for cardio/cerebrovascular disease Strategies to Reduce Television Time Start early – rules, access Content trumps time Family values: family time and schoolwork. Weekday time Television is a default behavior Use television to change behavior

17. International Conference for cardio/cerebrovascular disease Principal Strategies Physical activity Reduced television time Reduced soft drink consumption Breastfeeding Fruit and vegetable consumption Control of portion size

18. International Conference for cardio/cerebrovascular disease Observational Studies of Sugar-sweetened Beverage Consumption and Weight Change StudyPopulationFinding Striegel-Moore 2400 9-10 yo Positive relationship Ludwig548 11-12 yo Positive relationships Berkey 11000 9-14 yo Positive relationship in boys Welsh 11000 2-3 yo Positive relationship Phillips 132 9-10 yo Positive relationship with BMI Striegel-Moore R et al. J Pediatrics, 2006;in press. Ludwig et al. Lancet 2001;357:505. Berkey CS et al. Obesity Res 2004;12:778. Welsh J et al. Pediatrics 2005;115:223. Phillips SM et al. Obesity Res 2004;12:461.

19. International Conference for cardio/cerebrovascular disease Principal Strategies Physical activity Reduced television time Reduced soft drink consumption Breastfeeding Fruit and vegetable consumption Control of portion size

20. International Conference for cardio/cerebrovascular disease Overview of Weight Control Efforts Problem Definition Assessment Prevalence Disease burden Strategy Development Social Ecologic Model Community Guide Translation Implementation State Programs, Steps Policy/environmental Interventions Media Evaluation

21. International Conference for cardio/cerebrovascular disease Basic Implementation Capacity Building CDC Funded States for Nutrition & Physical Activity

22. International Conference for cardio/cerebrovascular disease State-coordinated Small Cities/Rural Communities WA – 4 counties AZ – 3 counties CO – 4 counties NY – 4 counties AL – 2 areas MN – 4 areas PA – 3 counties Tribes/Tribal Entities Intertribal Council of Michigan Cherokee Nation Health Services Group (Oklahoma) Southeast Alaska Regional Consortium Large Cities/Urban Communities Seattle-King County, WA Salinas-Monterey County, CA Austin-Travis County, TX New Orleans, LA St. Petersburg-Pinellas County, FL Boston, MA Philadelphia, PA San Antonio, TX Cleveland, OH Santa Clara County, CA Dekalb County, GA Hillsborough County, FL STEPS Awardees Representing 40 Communities

23. International Conference for cardio/cerebrovascular disease Settings for the Prevention and Treatment of Obesity Industry Medical Settings School Work Site Community

24. International Conference for cardio/cerebrovascular disease Environment Family School Worksite Community Medical System Information Systems Decision Support Delivery System Design Self Management Support Patient Self-Management Chronic Care Model

25. International Conference for cardio/cerebrovascular disease Priorities within Medical Settings and Plans Measurement of BMI Family history Stratification of care based on ROI Effective strategies for weight loss within primary care Reimbursement

26. International Conference for cardio/cerebrovascular disease

27. International Conference for cardio/cerebrovascular disease Behavior Change Strategies Strategy Control environment Set Goals Monitor behavior Reward success Example Eliminate CHO-drinks from home Eliminate TV sets from bedroom Limit of CHO-drinks to 4 oz/day Limit screen time to < 2 hrs/day Count & record drinks and TV time Praise and attention Extra privileges Dietz and Robinson. NEJM 2005;352:2100

28. International Conference for cardio/cerebrovascular disease Priorities within Medical Settings and Plans Measurement of BMI Family history Stratification of care based on ROI Effective strategies for weight loss within primary care Reimbursement

29. International Conference for cardio/cerebrovascular disease Environment Family School Worksite Community Medical System Information Systems Decision Support Delivery System Design Self Management Support Patient Self-Management Chronic Care Model

30. International Conference for cardio/cerebrovascular disease Settings for the Prevention and Treatment of Obesity Industry Medical Settings School Work Site Community

31. International Conference for cardio/cerebrovascular disease Application of the School Health Index Provides a self-assessment tool for schools Addresses both nutrition and physical activity practices Internally and locally motivated rather than externally imposed changes Allows evaluation of the impact

32. International Conference for cardio/cerebrovascular disease Priority Physical Activity and Nutrition Actions for Schools Coordinated school health program and school health council Assessment and planning (School Health Index) Quality health education Staff wellness programs Quality PE Additional opportunities for physical activity (e.g., recess, after school, walk to school) Healthy school nutrition environment

33. International Conference for cardio/cerebrovascular disease Settings for the Prevention and Treatment of Obesity Industry Medical Settings School Work Site Community

34. International Conference for cardio/cerebrovascular disease CDC Projects Related to Worksites Community Guide Recs Promising Practices Translate Findings Focus groups Disseminate Develop Cost Calculator Evaluate Develop Toolkits Implement Evaluate

35. International Conference for cardio/cerebrovascular disease Overview of Weight Control Efforts Problem Definition Assessment Prevalence Disease burden Strategy Development Social Ecologic Model Community Guide Translation Implementation State Programs, Steps Policy/environmental Interventions Media Evaluation

36. International Conference for cardio/cerebrovascular disease Adult per Capita Cigarette Consumption and Major Environmental and Policy Changes in the US 1900-1990 Year Thousands per year 1900191019201930194019501960197019801990 Great Depression End of WW II US Surgeon General’s first report Broadcast advertising ban Federal cigarette tax doubles First Medical reports linking smoking and cancer Fairness Doctrine messages on radio and television Nonsmoker’s rights movement begins 0 1 2 3 4 5

37. International Conference for cardio/cerebrovascular disease Division of Nutrition and Physical Activity and VERB Websites cdc.gov/nccdphp/dnpa cdc.gov/nccdphp/dash cdc.gov/youthcampaign VERBnow.com VERBparents.com healthierus.gov/steps