childhood obesity: the way forward susan dentzer editor-in-chief with thanks to the robert wood...

Childhood Obesity: The Way Forward

Susan DentzerEditor-in-Chief

With thanks to the Robert Wood Johnson Foundation for its generous support

Childhood Obesity: Overview and National Trends

William H. Dietz, MD, PhDDirector Division of Nutrition, Physical Activity, and ObesityCenters for Disease Control and Prevention

54

6 67

5

11 11

15 1516

17

19

17

0

5

10

15

20P

erce

ntag

e

1963-1970

1971-1974

1976-1980

1988-1994

1999-2000

2001-2002

2003-2004

Ages 6-11Ages 12-19

Prevalence of Overweight Among Children and Adolescents Ages 6-19 Years

Source: JAMA, April 5, 2006, Vol. 295, No. 13:1549 and Pediatrics 1998; 101:497

Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19 Years

0

10

20

30

40

50

1999-2000 2001-2002 2003-2004 2005-2006

Perc

en

t

Non-Hispanic White Non-Hispanic Black Mexican American

Ogden CL et al. JAMA 2008;299:2401

Changes in Obesity Prevalence by Race/ethnicity, Girls 2-19 Years

0

10

20

30

40

50

1999-2000 2001-2002 2003-2004 2005-2006

Perc

en

t

Non-Hispanic White Non-Hispanic Black Mexican American

Ogden CL et al. JAMA 2008;299:2401

Impact of Childhood Overweight (BMI > 95th percentile) on Adult Obesity (BMI > 30)

• 25% obese adults were overweight children• 4.9 BMI unit difference in severity• Onset < 8y more severely obese as adults (BMI = 41.7 vs 34.0) • 50% of adults with BMI > 40 were obese as children

Freedman et al, Pediatrics 2001; 108: 712

Costs of Obesity – 1998 vs 2008Costs of Obesity – 1998 vs 2008

1998 2008 Total costs $78.5 B/y $147 B/yMedical costs 6.5% 9.1%

Increased prevalence, not increased per capita costs, was the main driver of the increase in costs

Finkelstein et al. Health Affairs 2009; 28:w822

Average Daily Energy Gap (kcal/day) Between 1988-94 and 1999-2002

Excess Weight Gained(Lb)

Daily Energy Gap (kcal/day)

All Teens 10 110 -165

Overweight Teens 58 678 -1,017

Behavioral implications of 150 kcal:Replacing 1 can of soda (12 oz) with water (140 kcal)Reducing TV watching by an hour (167 kcal/day)1

Walking 1.9 hours instead of sitting (for a 30-kg boy) Increasing PE from 1 to 3 times/week (240 kcal)

Wang YC et al. Pediatrics 2006;118:e1721Wiecha et al. 2006; Arch Pediatr Adolesc Med 160:436

National, State and Local Disparities in Childhood Obesity

Findings from the 2007 National Survey of Children’s Health

Christina Bethell, Lisa Simpson, Scott Stumbo, Adam Carle, Narengeral Gombojav

*2003 versus 2007 rates of obesity are significantly different (P<0.05)

2003 2007Publicly Insured 39.6% 43.2%*Poor (< 100% FPL) 39.8% 44.8%*Hispanic 37.7% 41.0%*

The Nation: 2003 vs. 2007

Within State Disparities

ID=27.5MN=23.1

Significantly lower than U.S.

Lower than U.S., not significant

Higher than U.S., not significant

Significantly higher than U.S.

Low: UT/MN: 23.1%

High: MS: 44.4

Variation Across States

Both Across and Within State Disparities Widened

AK=33.9AZ=30.6

Within State Disparities

School Engagement Missed School Days Repeated a Grade

bStatistically significant differences exist in estimated prevalence across child subgroups for this variable based on a chi square test and p< .01.

Independent Impact on School Outcomes

Higher Odds of Poorer School Outcomes for Overweight or Obese Children

(Adjusted for Health Status, SES, etc.)

Not Being Engaged in School

1.32 greater odds

Missing 2 or more weeks of school in year

1.59 greater odds

Repeated a grade in school

1.42 greater odds

31.0

While being publicly insured and not having access to a park or recreation center independently predicts overweight/obesity in children, most overweight or obese children are still privately insured and have neighborhood amenities

A National Issue

How Much Should We Invest In Preventing Childhood Obesity?

Leonardo Trasande, MD, MPPMount Sinai School of Medicine

BackgroundPolicy makers generally agree that childhood obesity is a national problem and costly to our economy.

However, it is not always clear whether enough is being spent to combat it.

While continued research is needed to develop successful initiatives to prevent and treat obesity and overweight, estimating the economic benefits of successful intervention can permit policy makers to determine the level of investment in developing interventions that would be worth considering.

MethodsThis paper presented nine scenarios that assume three different degrees of reduction in obesity/overweight rates among children in three age groups.

A mathematical model was then used to project lifetime health and economic gains.

These data were then used to calculate the level of investment that would be cost-effective using widely accepted criteria in health care if it produced reductions in the number of obese or overweight children.

ResultsDuring childhood, U.S. children who were 12 years old in 2005 are estimated to incur $6.24 billion in attributable medical expenditures over their lifetime, and lose 2,102,522 Quality Adjusted Life Years will be lost as a result of being overweight or obese in adulthood.

A one point reduction of obesity in this age group would save $260.4 million in medical expenditures and 102,749 Quality Adjusted Life Years.

At a value of $50,000/Quality Adjusted Life Year, spending $2 billion a year would be cost-effective if it reduced obesity among twelve-year-olds by one percentage point.

ResultsRegardless of the degree of reduction in obesity/overweight and the age group in which the impact of prevention was studied, large investments no smaller than $103 million and potentially in the tens of billions of dollars, each year, would be warranted if it could produce small reductions in the number of children with this significant comorbidity.

DiscussionIn conveying the scope of the effort that should be undertaken, this analysis took a conservative approach, analyzing only direct medical expenditures in childhood and adulthood and Quality Adjusted Life Years lost as a result of obesity/overweight in childhood.

This analysis suggests that even some costly interventions of uncertain efficacy and additional research to develop interventions may even be worth pursuit on a broad scale, if they actually produce success in reducing the number of overweight/obese children.

As debate about health reform continues, this manuscript provides additional data to underscore the need to focus on child health and especially on prevention as a mechanism to improve health cost-effectively.

A Statewide Strategy To Battle Child Obesity in DelawareMarch 2010

Debbie I. Chang ([email protected])Allison Gertel-RosenbergVonna L. DraytonShana SchmidtGwendoline B. Angalet

www.nemours.org

This research was funded, in part, by the Robert Wood Johnson Foundation

360o of Child Health Promotion: Impacting a Child Throughout the Day

Progress Results at the Population Level Results from the 2008 DSCH, compared to the 2006 DSCH, suggest that the

prevalence of overweight and obesity has leveled off for children ages 2 -17 years in Delaware

– Overweight remained unchanged at 17%

Evidence indicates the prevalence of obesity and overweight has leveled off in all Delaware counties and within subpopulations

Disparities still remain among racial groups

Household awareness between 2006-2008 of the 5-2-1-Almost None campaign increased fourfold (5% to 19%)

When parents were aware of the 5-2-1-Almost None message, significantly more children engaged in:

– 1 hour of physical activity per day (26% versus 10% if parent not aware of campaign)

– Moderate to vigorous physical activity for more than 20 minutes (33% versus 21% if parent not aware of campaign)

Progress Results - Child Care and School Child care regulations adopted statewide in 2007 reflect NHPS’ 5-2-1-Almost None healthy lifestyle behaviors

81 % of child centers participating in NHPS’ learning collaborative made significant changes in healthy eating and physical activity practices

Schools were 4 times as likely to report implementation of the federally-mandated wellness policy if district policy included specific Nemours-recommended content and language

School changes include healthy vending, evidence-based physical fitness programs, fitness equipment, and activity breaks

Principles and staff identified the following facilitated implementation:–Technical assistance; Networking with other districts/schools; Support from other school administrators

Schools participating in fitness pilot of 150 minutes of physical activity per week:–Increased fitness level as measured by FITNESSGRAM® tests–Students 1.5 times more likely to achieve Healthy Fit Zone, an indicator of fitness

Progress Results in Primary Care Primary Care providers receiving technical assistance from NHPS are more likely

to provide children with appropriate screening, care, and treatment for overweight and obesity

Delaware Primary Care Quality Improvement Initiative

19 multidisciplinary primary care teams achieved high results:– 98.2% of providers classified BMI or weight-for-length in 2009 (83% in 2007)– 88.6% of providers provided counseling on healthy lifestyles in 2009 (72.7% in 2007)– 88.1% of providers developed a care plan and family-management goals with obese/overweight

patients who were ready to change in 2009 (74.2% in 2007)

Nemours’ providers:– Nemours’ provider classification of BMI during well child visits doubled, 49% (2007)

to 94% (2008) – Nemours’ providers offer lifestyle counseling to 95% of all patients (almost double the national

reported rate of 54.5%)– Health promotion was built into Nemours’ Electronic Medical Record (EMR)

Lessons Learned Sustaining policy and practice changes

– Policy and practice change, together, in multiple sectors is critical– Policy can drive practice and practice can drive policy – Community capacity is critical to sustainability and to promoting, supporting and

implementing change Create strong partnerships

– Develop strong relationships with influential organizations– Clearly define roles among partners, understand partners’ reasons for involvement– Provide partners with data, tools and training to make recommended changes

Focus on maintaining strategy– Clearly defined program goals are critical to success– Focus on a limited set of priority areas and sectors to avoid dilution of effort and

impact Design an evaluation that works

– Acknowledge the strengths and limitations of the evaluation– Outcome measures (BMI) should remain a focal point– Align evaluation efforts with strategy– Achieving outcomes takes time - establish intermediate milestones to help track

progress– Focus on demonstrating broad association and linkages where possible

Childhood Obesity: The New Tobaccoor…Childhood Obesity as a Social Movement: Lessons from Tobacco

Jonathan D. Klein, MD, MPHAmerican Academy of Pediatrics

William C. Dietz, MD, PhDCenters for Disease Control and Prevention

• Shared, personalized perception of a threat

• Common framing of the problem

• Grass roots commitment

• Social network focused on collective action

• Local nodes with dense social ties, linked to

others with weak bridging ties (rapid diffusion)

• Organizational structure realignment

Social Movements

• Surveillance/data- led to recognition of the problem

• Early voices - scientists and advocates

• Industry deception and secondhand smoke harm to others became common frame - leading to changing social norms

• Uniting against common enemy - cigarette companies - lead to political will and policy changes

• Organized movement - realignment of framing

Tobacco’s success

• Surveillance/data- recognition as a pressing problem

• Early alarmed voices - scientists, advocates, funders

• No common frame - physical activity, eating, both• Personal responsibility/choice• Toxic food environment• Industry role mixed

• No parallel to non-smokers rights movement

• Advocates are not coordinated (breastfeeding, social justice, local food, disease prevention, environment)

Where Are We For Obesity?

• Practice based interventions–Medical home–Access to levels of care–Family centered care

• Community and policy based interventions–Nutrition programs–Physical activity promotion–Physical environment–Sugar sweetened beverages–Food labeling and marketing

What Can Clinicians Do?

Social Strategies

ScientificKnowledge

Political Will

Do we have the political will?

AAP pledges to:• Body Mass Index (BMI %ile) • Prescription for healthy, active living

…and information about

how to achieve healthy weight,and on the impact of eating and physical activity on health

Overcoming obesity in this generation

Impact of Childhood Obesity On Employers

M-J. Sepúlveda, MD FACPIBM Fellow & Vice President, Integrated Health ServicesIBM Corporation

The Framework Of Parent-Child Interactions Potentially Affecting Employers

• Parents promote obesity in children

• Obese children beget 1 of 4 obese adults

• Both incur high costs in health care

• Caregiving for physical and psychosocial needs consume adult time and energy from work

Parent Health Child Health

Health care costs

Absenteeism,Presenteeism

Future Workforce

Parent Behavior Child Behavior

Adult Health

Employer

Parent Performance

Health care costs

The Direct Financial Impact on Employers

• Average claims costs for obese adults as well as obese children are nearly twice that of the non-obese

• Average claims cost of children with type II diabetes exceeds the average claims cost of adult type II diabetics

Source: IBM, 2008 claims based on obesity diagnosis and costs

$1,640

$10,789

$2,907$4,520

$8,844$8,889

Non

-obe

se

Obe

se

TII D

iabe

tes

TII D

iabe

tes

Obe

se

Non

-obe

se

Children (18 and under)

Adults

Children’s Health Rebate

1- baseline inventory2- set goals3- track and report

What we’ve learned so far …. Families engage, 11.7K earn rebate in 2008 – many add own goals…

“Kids write what fruits and veggies they want” “No parents’ TV or computer between 6 & 9 PM”“Start with smaller portions and have kids ask for seconds” “Both parents in the pool during children’s swim lessons” “Adults watch portion sizes on desserts”

Families change behavior, some change is harder than others

Source: IBM, 2008 Children’s Health Rebate Earners

Families value program, IBM

Children eat healthy breakfast 5+days

Children eat healthy dinner 5+days

Family eats/prepares healthy meals together 5+ days

Children get physical activity 5+days

Family is physically active together 3+days

Children have < 1hr entertainment screen time

Adults have < 1hr entertainment screen time

Children eat only healthy snacks on typical day

Children eat 5+ fruits/veggies

Percent of Participants (N=11,743)

Beginning of Program

End of program (12 weeks)

Motivating Employers to Act Employer population data: prevalence rate, direct costs, +/- productivity costs

Benchmark data: community, competitor, best practices

- Health care providers to diagnose and code - De-identified data sets: geographic trends from new government registries

and costs from health plans Evidenced based solutions from providers, insurers, non profits, government agencies

Employer Opportunities to Act Workforce policies: flexible work arrangements, access to health promotion programs

Health benefits coverage for overweight/obesity care and support services

Payment and demands for pediatric medical home services

Innovative collaborations with employer groups, health care provider organizations, public health agencies and communities

Specialized Care of Overweight Children in Community Health Centers

Shikha Anand, MD, MPH

Components of High Quality Pediatric Obesity Treatment1. Assessment of Medical Risk – labs, family history review,

medical exam

2. Nutrition Assessment – junk food, sweetened beverages, fast food, fruits and vegetables

3. Activity Assessment – screen time and physical activity

4. Health Behavior Change - goals for lifestyle change set by patient

5. Monthly follow-up (recommended by the American Academy of Pediatrics)

Current Options for Obesity Treatment

1. Specialty Care in Hospital Clinics• Pros: Includes nutrition, physical activity, medical assessment and health

behavior change in a single visit• Cons: Expensive, monthly visits outside of primary care office –

inconvenient, difficult to coordinate with primary care clinic

2. Monthly Visits in Primary Care• Pros: Convenient for families, cheaper than hospital-based care• Cons: Provider not trained in obesity or health behavior change, obesity

visits are difficult to schedule – take longer than usual primary care visits, other providers such as dieticians not included in visits - need to schedule additional visits to see other providers

3. Specialized Primary Care• Combines expertise offered in specialty clinics with convenience and cost

savings of primary care

Specialized Primary Care Treatment of Obesity1. The Model• Monthly multi-disciplinary clinic visits for overweight children• Medical provider, dietician, case manager in a single visit• Assess medical risk factors, nutrition, and activity• Promote health behavior change• Visits occur within the community health center where a child receives

primary care

2. The Setting• Eight community health centers in Massachusetts• Urban and rural clinics, provide pediatric primary care • Target poor and minority children

3. Early results• 174 children with more than one clinic visit in first 14 months• 50.0% decreased BMI, 100.0% set goals for lifestyle change (increased

activity, decreased sweetened beverages, etc), 79.8% reported making such a change at a later visit

Implications for Future Practice

1. Improved effectiveness over current standard of obesity treatment in pediatric primary care

2. Increased efficiency by combining multiple providers in a single visit

3. Decreased cost compared to hospital-based clinics

4. Replication in eight diverse community health centers indicates that model is scalable

5. Specialized, multi-disciplinary primary care could be expanded to other common chronic conditions including ADHD and asthma

Acknowledgements

1. Bill Adams, MD and Barry Zuckerman MD

2. Healthy weight Clinic Teams: Holyoke, Greater Lawrence, Codman Square, Whittier Street, Greater New Bedford, Outer Cape, Lowell, and Bowdoin Street Community Health Centers

3. Healthy Weight Initiative Staff: Penny Marston and Deirdre Connor, MPA

4. Howard Bauchner, MD

5. Vijay Nayak, MD

6. Funding for this work provided by CAVU Foundation and Paul and Phyllis Fireman Foundation

Specialized Care of Overweight Children in Community Health Centers March 1, 2010 Page 01

Specialized Care of Overweight Children in Community Health Centers

Shikha Anand, MD, MPH

Evidence-Based Components of High Quality Pediatric Obesity Treatment


1. Assessment of Medical Risk – labs, family history review, medical exam

2. Comprehensive Nutrition Assessment – junk food, sweetened beverages, fast food, fruits and vegetables

3. Activity Assessment – screen time and physical activity

4. Health Behavior Change - goals set by patient for diet and activity changes, facilitated by provider with training in motivational interviewing

5. Monthly follow-up (recommended by the American Academy of Pediatrics)

Current Options for Medical Obesity Treatment

1. Specialty Care in Hospital Clinics• Pros: Includes nutrition, physical activity, medical assessment and health

behavior change in a single visit• Cons: Expensive, monthly visits outside of primary care office –

inconvenient, difficult to coordinate with primary care clinic

2. Monthly Visits in Primary Care• Pros: Convenient for families, cheaper than hospital-based care• Cons: Provider not trained in obesity or health behavior change, obesity

visits are difficult to schedule – take longer than usual primary care visits, other providers such as dieticians not included in visits - need to schedule additional visits to see other providers

3. Specialized Primary Care• Combines expertise offered in specialty clinics with convenience and cost

savings of primary care


Specialized Primary Care Treatment of Obesity1. An Innovative Model• Monthly multi-disciplinary clinic visits for overweight children• Medical provider, dietician, case manager in a single visit• Assess medical risk factors, nutrition, and activity• Promote health behavior change

2. Delivery Within Underserved Communities• Visits occur within the community health center where a child receives

primary care• Urban and rural clinics, provide pediatric primary care • Target poor and minority children

3. Promising Early Results• 174 children with more than one clinic visit in first 14 months• 50.0% decreased BMI, 100.0% set goals for lifestyle change (increased

activity, decreased sweetened beverages, etc), 79.8% reported making such a change at a later visit

• Exciting given the challenges of treating obesity in underserved youth


Elements of our Community-Oriented Initiative Beyond the Model1. Exciting Clinic-to-Clinic Collaboration• Model pilot tested at a single clinic in 2006 and then spread to eight

community health centers in Massachusetts in 2008 and 2009• Clinics have conference calls every month and face-to-face meetings twice

every year• Interactions serve as basis for quality improvement, problem-solving, and

best-practice sharing throughout initiative• Centralized technical assistance team provides support for these

interactions as well as expert advice for clinics

2. Innovative Use of Health Information Technology• Standardized clinical encounter form drives care quality at each

community health center• Web-based data collection system yields graphical analysis of health

outcomes• Quarterly review of data with clinics to drive improvement over time


Implications for Future Practice

1. Improved effectiveness over current standard of obesity treatment in pediatric primary care

2. Increased efficiency by combining multiple providers in a single visit

3. Decreased cost compared to hospital-based clinics

3. Tie in to current patient-centered medical home movement occurring in community health centers nationwide

4. Replication in eight diverse community health centers indicates that model is scalable

5. Specialized, multi-disciplinary primary care could be expanded to other common chronic conditions including ADHD and asthma


Acknowledgements

1. Bill Adams, MD and Barry Zuckerman MD

2. Healthy Weight Clinic Teams: Holyoke, Greater Lawrence, Codman Square, Whittier Street, Greater New Bedford, Outer Cape, Lowell, and Bowdoin Street Community Health Centers

3. CAVU Staff: Penny Marston and Deirdre Connor, MPA

4. Howard Bauchner, MD

5. Vijay Nayak, MD

6. Funding for this work provided by CAVU Foundation and Paul and Phyllis Fireman Foundation


The Role of the Built Environment and Neighborhood Conditions in Childhood Obesity

Gopal K. Singh, Ph.D.U.S. Department of Health & Human Services Health Resources & Services Administration

Maternal and Child Health Bureau

Obesity Prevalence (%) by Neighborhood Built Environment Index, 2007

2019

17

15

33

26

20

15

10

15

20

25

30

35

Fewest neighborhood amenities

2nd fewest neighborhood

amenities

2nd most neighborhood

amenities

Most neighborhood amenities

All Children Aged 10-17

Female Children Aged 10-11

Source: Singh GK, Siahpush M, Kogan MD. Health Affairs. Vol. 29, No. 3. March 2010.

Prevalence (%) of Physical Inactivity and TV Viewing Time byBuilt Environment Index, Children Aged 10-17 Years, 2007

17

1212

11

28

2524

22

5

10

15

20

25

30

Fewest neighborhood amenities

2nd fewest neighborhood

amenities

2nd most neighborhood

amenities

Most neighborhood amenities

No Physical Activity Watch TV > 2 hours/day


Excess Obesity Risk (Percent Higher Odds) Among Children Aged 10-17 From Unfavorable Neighborhood Built Environments, 2007

3432

26

20

15

10

15

20

25

30

35

Built Environment Index (low vs high

amenities)

No access to sidewalks or walking

paths

No access to parks or playgrounds

No access to recreation or

community centers

No access to library or bookmobile


Excess Obesity Risk (Percent Higher Prevalence) Among Children in Unfavorable Neighborhood Social Conditions, 2007

34

43

33

24

6

93

80

55

64

37

0

20

40

60

80

100

Social conditions (least vs most

favorable)

Unsafe neighborhood

Garbage/litter in streets or sidewalks

Poorly kept or rundown housing

Vandalism (broken windows or graffiti)

All Children Aged 10-17

Female Children Aged 10-11


Policy Solutions to the Grocery Gap

Allison Karpyn Director of Research and EvaluationThe Food Trust

Replicating Pennsylvania’s Fresh Food Financing Initiative

Identification of Areas of Need

Lessons Learned

• Adapt to Local Circumstances

• Maintain Focus

• Engage Diverse Sectors

• Include Industry

• Nurture Local Efforts

• Conduct More Research

Sodexo’s Commitment to Student Well-Being

Roxanne E Moore MS, RDNational Director of WellnessSodexo Education

65

Sodexo encourages student well-being

Sodexo was one of the first companies to join the MyPyramid Corporate Challenge to promote the USDA's dietary guidelines

Sodexo is the first foodservice company to formally adopt the snack and beverage guidelines from the Alliance for a Healthier Generation, a joint initiative of the American Heart Association and the William J. Clinton Foundation

As a participant in the National School Lunch Program and the School Breakfast Program, Sodexo culinary professionals create menus for school districts that meet or exceed all USDA nutritional guidelines for school meals

Sodexo educates students on good nutrition

Not only does Sodexo feed kids, but we also help to educate them

● Nutrition labeling● A to Z Salad Bar● Produce of the Month● Kids Cooking● School Gardens● Los Kitos● Age-appropriate nutrition education

Sodexo supports teachers with materials to aid with nutrition education lessons

Sodexo managers, chefs and dietitians work with parents, nurses, administrators, PTAs and district wellness committees to create nutrition programs that nourish and educate students

Sodexo partners with First Lady’s Let’s Move initiative

First Lady Michelle Obama is seeking the support of business leaders to end the epidemic of childhood obesity with the Let’s Move initiative

Sodexo is helping this fight by making nutritious school lunches affordable and accessible to all students and by focusing on nutrition education in the schools we serve

Sodexo’s support of HealthierUS School Challenge certification efforts is a great example of how we fight obesity on the local level

Sodexo helps schools get certified in the HealthierUS School Challenge

To earn HealthierUS School Challenge certification, school districts must meet a wide variety of guidelines that include menu planning, nutrition education and physical activity

Sodexo meets with clients to collaborate on the certification process, including the development of new programs, promotions and activities that help district’s meet the USDA requirements

Along with menu planning, Sodexo uses its many resources to assist clients with education and physical activity requirements

Sodexo fights to end childhood hunger

Research shows that poverty is a major contributor to childhood obesity

Sodexo School Services uses innovative programs to end hunger in the communities we serve

Breakfast in the Classroom programs bring delicious and nutritious meals directly to the students to ensure that they get the fuel they need to succeed in school

The Backpack Program provides nutritious weekend meals to students that might otherwise go without

Helping Hands Across America encouraged Sodexo employees to fight hunger locally and included a company-wide canned food drive

Agriculture Policy & Childhood ObesityA Food Systems and Public Health Commentary

David WallingaDirector, Food and Health Program Institute for Agriculture and Trade Policy

Agriculture policy since 1974: “Cheap food”

Success as a cheap calorie policy

• Production-driven• Export-driven

Commodity subsidies not written into Farm Bill until 2002

Of 300 calorie excess, relative to 1985 Of 300 calorie excess, relative to 1985 (Putnam et al. 2002(Putnam et al. 2002))

Added sweeteners account for 23 percentAdded sweeteners account for 23 percent Added fats account for 24%Added fats account for 24% Grains, mostly refined, account for 46 percent

Linked to Linked to obesity obesity

promotionpromotion

400

Economic Research Service. Loss adjusted food availability [database on the Internet]. Washington Economic Research Service. Loss adjusted food availability [database on the Internet]. Washington (DC): U.S. Department of Agriculture; updated 2009 Feb [cited 10 Jan 2010]. Available from: (DC): U.S. Department of Agriculture; updated 2009 Feb [cited 10 Jan 2010]. Available from: http://www.ers .usda.gov/Data/FoodConsumption/ FoodGuideIndex.htm .usda.gov/Data/FoodConsumption/ FoodGuideIndex.htm

http://www.ers/

38.9%

20.4%

11.5%

-0.6%-3.2% -4.5%

-7.0%

-14.0%

-23.6%-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%Fresh fruits & veggies

Total fruits & veggies

Red meatsDairy

Cereal & baked goods

Sugars & sweets

Fats & oils

Soda pop

Poultry

Change in food prices, 1985 –2000, real $

Foods high in fats, sugars and calories are some of the least expensive, most inflation-resistant in the American food environment.

Wallinga D. Today's food system: how healthy is it? J Hunger Environ Nutr 2009;4(3):251-81.

Near-term policy changeNear-term policy change

• A food systems analysis commensurate with the A food systems analysis commensurate with the complexity of the health problems.complexity of the health problems.

• Farmers as partners against childhood obesity.Farmers as partners against childhood obesity.

• Agriculture research to achieve synergies between Agriculture research to achieve synergies between growing healthier foods, with fewer fossil fuels, and growing healthier foods, with fewer fossil fuels, and with American farmers.with American farmers.

A Healthy Food, Healthy Farm Bill

American spending on food, health relative to disposable income

Figure 1 , Wallinga D. Today's food system: how healthy is it? J Hunger Environ Nutr 2009;4(3):251-81.

Are “Competitive Foods” Sold at Schools Making Our Children Fat?Nicole Larson PhD, MPH, RD Mary Story PhD, RD

Competitive Foods in U.S. Schools:A Review of the Evidence

• Purpose: Conduct a comprehensive review of the research to :– Examine the availability and nutritional

content of competitive foods in schools– Examine the impact of competitive foods

on students’ dietary intake and students’ weight status

• Methods: Literature search of peer-reviewed studies from 1999-2009

• Discuss policy implications

Competitive Foods and Dietary Intake• 17 peer-reviewed studies

– All 9 observational studies– 4 of 8 policy evaluations/interventions

• Students have better diets when unhealthy foods are not available at school

• Students may purchase & consume more healthful foods (e.g., fruits & vegetables) when they are available at school

Competitive Foods and Weight Status• 6 peer-reviewed studies

– All 3 observational studies– All 3 multi-component intervention studies

• Greater availability of unhealthy foods at school related to higher body fatness

• Limiting the availability of unhealthy foods at school was a component of successful interventions shown to reduce overweight

Schools and Competitive Foods: What do we know?Nutritionally poor foods are widely available in schoolsFindings from SNDA-III (2004-2005)

• Nationally, 1 or more sources of competitive foods were available in 73% of elementary schools, 97% of middle schools and 100% of high schools.

• Overall, 40% of students consumed 1 or more competitive foods on a typical school day and consumption increased with grade level.

• Healthy foods and beverages are increasingly available, but the most common items sold outside school meals are candy, sugary drinks, salty snacks and desserts.

Bottom line: While schools have made improvements, more is needed.

What is the impact of competitive foods on child nutrition?Findings from SNDA-III

• Students who ate competitive foods/beverages at schools on average consumed 277 Kcal/day; two-thirds of these Kcal (177) were from low-nutrient, energy dense sources.

• The availability of snacks and drinks sold in schools are associated with higher student intakes of total calories, soft drinks, total fat and saturated fat intakes and lower intakes of fruits and vegetables and milk.

• The availability of junk foods in vending machines in or near the school cafeteria in middle schools was associated with higher than average body fatness.

• School food policies and practices that limited the availability of competitive beverages were associated with reduced consumption of calories from sweetened beverages schools. Students did not “make up” by drinking more outside of school.

Institute of Medicine’s Institute of Medicine’s Nutrition Standards for Foods in Schools Nutrition Standards for Foods in Schools (2007)(2007)

Major conclusions:1. Opportunities for competitive foods

should be limited. The federal school nutrition programs should be the main source of nutrition at schools.

2. If competitive foods are available, they should consist of nutritious fruits, vegetables, whole grains, and nonfat or low-fat milk/dairy products, plain water, 100% juice (4-8 oz).

Competitive Foods: Our current situation

• Federally subsidized school meals are required by Congress and USDA to meet nutrition standards and comply with the Dietary Guidelines for Americans.

• Standards for competitive foods are 30 yr old and don’t address calories, fats, salt, and sugars.

• The USDA does not have authority to regulate foods or beverages sold outside the cafeteria or outside mealtimes.

Not Allowed

Current competitive food standards don’t make sense

Allowed

Fruitades (with little juice)

French fries Ice cream

barsCandy bars

CookiesChips

Snack cakesDoughnuts

Seltzer waterCaramel corn

Popsicles (without fruit juice)

Jelly beansChewing gum

LollipopsCotton candyBreath mints

Policy Recommendations: What is Needed?

Update the national nutrition standards for competitive foods and beverages to bring them in line with the Dietary Guidelines and apply them to the whole campus for the entire school day. The new standards should:– Restrict the sale of sugar-sweetened beverages

throughout the day in all schools.

– Limit the availability of low-nutrient, energy-dense foods sold a la carte and in vending machines and fundraisers.

– Promote children’s consumption of fruits, vegetables, whole grains and non-fat or low-fat dairy products.

Childhood Obesity: The Way Forward

With thanks to the Robert Wood Johnson Foundation for its generous support

childhood obesity: the way forward susan dentzer editor-in-chief with thanks to the robert wood...

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