Critical and Emerging Strategies
for Obesity Prevention and Care
William H. Dietz MD, PhD
Director:Redstone Global
Center for Prevention and Wellness
Most Recent Obesity Trends in Youth 2-19 y:
2-year surveys
No significant linear trend over the
last 10 years 2003-2004 to 2011-2012
overall or in boys or girls
Ogden et al. 2012, NCHS data brief; Ogden et al. 2014 JAMA
Childhood Obesity Trends Over Time in 2-5
Year-Old U.S. Children
States and Communities Reporting Decreases in the Prevalence of
Childhood Obesity
Portland, ME
King
County
Kearney, NE
Cambridge, MA
Somerville, MA
DuPage County,
IL
Fitchburg, MA
MA
New York
City
OH
Philadelphia, PA
WV
CA
Vance, NC
Granville, NC
San Diego, CA
NM
MS
Chula Vista, CA
El Paso, TX
Anchorage, AK
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
Frequency of Exposure to ACEs (n=8056)
Frequency
Zero
One
Two
Three
Four
%
49.5%
24.9%
12.5%
6.9%
6.2%
Fellitti VJ et al. Am J Prev Med 1998;14:245
Consequences of Exposure to ACES
Smoking
Illicit drug use
Adult alcohol abuse
Unintended pregnancy
Sexually transmitted diseases
Attempted suicide
Depression
Severe obesity
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)
Changes in Physical Activity
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Increased use of appliances
Elimination of PE and recess
Suburbanization
Increased car use
Post-industrial society – shift from
manufacturing to service economy
Shifts in Food Practices in the United States
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13
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
Daily Energy Deficits Necessary to Achieve the HP
2010 Goal (Prevalence = 5%) by 2020
Age
2-5 yo
Deficit
33 kcal/d
6-11 yo
149 kcal/d
12-19 yo
177 kcal/d
Adults
220 kcal/d
Wang YC et al. Am J Prev Med 2012; 42:437
Hall KD et al. Lancet 2011;378:826
Changes in Food Consumption in the US
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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
Social Ecological Model
Greatest
Impact
Federal and State
Community
Institutions
Interpersonal
t
lll
Individual
Smallest
Impact
Federal, state and local
policies to regulate and
support healthy actions
Policies, standards,
social networks
Policy, regulations
and informal structures
Family, peers, social
networks
Knowledge, attitudes,
beliefs and behaviors
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
Settings for the Prevention and
Management of Obesity
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Early care & education
Schools
Communities
Medical systems
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
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
Opportunities for School-wide Physical
Activity
Kohl HW III, Cook HC. Educating the Student Body, IOM 2013.
Programs to Increase Physical Activity in
Youth
• CDC funds for comprehensive
physical activity programs
• Let’s Move Active Schools
• Presidential Youth Fitness
Program
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
The Fittest American Cities (Metropolitan
Statistical Areas)
City
1. Washington DC
2. Minneapolis/St. Paul
3. Portland
4. Denver
5. San Francisco
34. Kansas City
41. St. Louis
Score
77.3
73.5
72.1
71.7
71.0
45.1
41.3
ACSM American Fitness Index 2014
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
Chronic Care Model
Environment
Medical System
Family
School
Information Systems
Family/Patient
Self-Management
Worksite
Community
Dietz WH et al. Health Affairs 2007;26:430
Decision Support
Delivery System Design
Self Management Support
Language in Obesity Counseling
Terms to Use
Weight
Unhealthy weight
Healthier weight
Increased BMI
Eating habits
Physical activity
Terms to Avoid
Obesity
Heaviness
Fat
Unhealthy BMI
Diet
Exercise
Puhl R et al. Int J Obesity 2013;37:612
Wadden T & Didie E. Obesity Res 2003;11:1140
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
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
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
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
Let’s Move Initiatives
• Let’s Move Outside (Parks and Recreation)
• Let’s Move Cities, Towns, & Counties
• Chefs Move to Schools
• Let’s Move Salad Bars to School
• Let’s Move Child Care Challenge
• Let’s Move in Indian Country
• Let’s Move Active Schools
• Drink Up!
Challenges
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Is obesity the right frame? Healthy
weight?Wellness? Diabetes?
Apply strategic thinking to choices of interventions
More practice-based evidence
Evaluation – if it can’t be measured it won’t be done
Long-term investments
Uncertainty regarding the sustainability of the
federal response
Importance of state and local solutions