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William H. Dietz MD, PhD Director:Redstone Global Center for Prevention and Wellness Critical and Emerging Strategies for Obesity Prevention and Care

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Most Recent Obesity Trends in Youth 2-19 y: 2-year surveys Ogden et al. 2012, NCHS data brief; Ogden et al. 2014 JAMA No significant linear trend over the last 10 years 2003-2004 to 2011-2012 overall or in boys or girls

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Childhood Obesity Trends Over Time in 2-5 Year-Old U.S. Children

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States and Communities Reporting Decreases in the Prevalence of Childhood Obesity El Paso, TX NM CA MS Anchorage, AK Chula Vista, CA Kearney, NE WV Vance, NC Granville, NC Philadelphia, PA New York City Fitchburg, MA Somerville, MA Cambridge, MA Portland, ME DuPage County, IL OH San Diego, CA MA King County

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Adverse Childhood Experiences (ACEs) Victimized or witnessed abuse Verbal Sexual Physical Exposures Poverty Incarceration Homelessness Household instability divorce, separation, death Mental illness or maternal depression Drug or alcohol abuse

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Frequency of Exposure to ACEs (n=8056) Frequency % Zero49.5% One24.9% Two12.5% Three 6.9% Four 6.2% Fellitti VJ et al. Am J Prev Med 1998;14:245

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Consequences of Exposure to ACES Smoking Illicit drug use Adult alcohol abuse Unintended pregnancy Sexually transmitted diseases Attempted suicide Depression Severe obesity

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Impact of Early Adverse Experiences on Obesity 40% increased risk of obesity 90% increased risk of severe obesity associated with verbal abuse Population attributable fraction of any abuse = 8% obesity and 17% severe obesity (BMI > 40)

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Changes in Physical Activity Increased use of appliances Elimination of PE and recess Suburbanization Increased car use Post-industrial society shift from manufacturing to service economy

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Shifts in Food Practices in the United States Increased cost of healthful foods Decreased cost of junk foods Increased portion size Increased processed foods Increased variety Increased availability Increased school vending and a la carte foods 13

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Daily Energy Deficits Necessary to Achieve the HP 2010 Goal (Prevalence = 5%) by 2020 Age Deficit 2-5 yo 33 kcal/d 6-11 yo149 kcal/d 12-19 yo177 kcal/d Adults220 kcal/d Wang YC et al. Am J Prev Med 2012; 42:437 Hall KD et al. Lancet 2011;378:826

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Changes in Food Consumption in the US Between 1999-2000 & 2009-10, sugar drinks declined by 68 kcal/d in 2-19 yo* Between 2003-4 & 2007-8, fast food consumption decreased by 64 kcal/d (25%) in 2-11 yo and 14 kcal/d (3%) in 12-19 yo** Between 2003-4 and 2009-10, pizza consumption decreased by 27 kcal/d (25%) in 2-11 yo*** Healthy Weight Commitment Foundation 78 kcal/d *Kit et al. Am J Clin Nutr May 15, 2013;doi:103945 **Powell & Nguyen. Am J Prev Med 2012;43:498 ***Powell et al. Pediatrics 2015; Jan 19 online release

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Social Ecological Model t lll Individual Federal and State Community Interpersonal Greatest Impact Smallest Impact Institutions Federal, state and local policies to regulate and support healthy actions Knowledge, attitudes, beliefs and behaviors Family, peers, social networks Policy, regulations and informal structures Policies, standards, social networks

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People First Language Obese is an identity Obesity is a disease An obese person is more likely to be held responsible tor their weight Describing a person with obesity is more likely to focus attention on cause

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Settings for the Prevention and Management of Obesity Early care & education Schools Communities Medical systems Early care & education Schools Communities Medical systems

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Strategies for Early Care and Education Regulations Standards for PA Limits on screen time Healthful foods and beverages Training and technical assistance Accountability Quality Improvement Rating Systems (QRIS) Self-assessment NAP-SACC

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Strategies for Schools Nutrition Remove sugar drinks and junk food Implement competitive food policies School wellness councils Physical activity (PAG Mid-course review) Multicomponent programs Physical education Activity breaks

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Opportunities for School-wide Physical Activity Kohl HW III, Cook HC. Educating the Student Body, IOM 2013.

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Programs to Increase Physical Activity in Youth CDC funds for comprehensive physical activity programs Lets Move Active Schools Presidential Youth Fitness Program

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Strategies for Communities Parks and recreation Proximity Safety Programming and promotion Healthy food and beverage offerings Land use Safe routes to school (active transport) Complete streets

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The Fittest American Cities (Metropolitan Statistical Areas) CityScore 1. Washington DC 77.3 2. Minneapolis/St. Paul 73.5 3. Portland 72.1 4. Denver 71.7 5. San Francisco 71.0 34. Kansas City 45.1 41. St. Louis 41.3 ACSM American Fitness Index 2014

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Strategies for Communities Parks and recreation Proximity Safety Programming and promotion Healthy food and beverage offerings Land use Safe routes to school (active transport) Complete streets

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Environment Family School Worksite Community Chronic Care Model Medical System Information Systems Decision Support Delivery System Design Self Management Support Family/Patient Self-Management Dietz WH et al. Health Affairs 2007;26:430

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Language in Obesity Counseling Terms to UseTerms to Avoid WeightObesity Unhealthy weightHeaviness Healthier weightFat Increased BMIUnhealthy BMI Eating habitsDiet Physical activityExercise Puhl R et al. Int J Obesity 2013;37:612 Wadden T & Didie E. Obesity Res 2003;11:1140

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Why Weight? www.whyweightguide.org Facilitates the initiation of open and productive conversations about weight Assesses patient readiness Promotes active listening Establishes realistic goals Builds trust Addresses culture and social support

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How Can We Best Engage Families? Adverse risk factors Presence of health effects Impaired activities of daily living Bullying (Bully or the Bullier) Family history

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Competencies Relevant to Obesity Prevention and Control Use of appropriate terms for obesity Sensitivity to bias and stigma Behavior change strategies Ability to work with and within teams Use of information technology Ability to work across sectors - Interdisciplinary - Clinical:community Align clinical services with severity Focus on health as well as disease

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Weigh In: Talking with your Children about Weight and Health Free e-guide for parents of children 7-11 yo Helps parents discuss weight and health with their children Real-world situations and plain language responses Avoids blame; provides ways to have conversations about the following: BMI confusion Body image Bullying Weight bias Inter-family weight differences and parental obesity

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Lets Move Initiatives Lets Move Outside (Parks and Recreation) Lets Move Cities, Towns, & Counties Chefs Move to Schools Lets Move Salad Bars to School Lets Move Child Care Challenge Lets Move in Indian Country Lets Move Active Schools Drink Up!

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Challenges Is obesity the right frame? Healthy weight?Wellness? Diabetes? Apply strategic thinking to choices of interventions More practice-based evidence Evaluation if it cant be measured it wont be done Long-term investments Uncertainty regarding the sustainability of the federal response Importance of state and local solutions