Linking Personal Responsibility, Economics, and
Policy Change to Lifestyle Behaviors
William H. Dietz, MD, PhD
Director of the Division of Nutrition, Physical
Activity, and Obesity
Centers for Disease Control and Prevention
Obesity Trends Among U.S. Adults
BRFSS, 1990, 1999, 2009
1999
1990
2009
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Changes in Obesity Prevalence by Race/ethnicity, Boys 2-19
Years
Non-Hispanic White
Non-Hispanic Black
Mexican American
50
Percent
40
30
20
10
0
1999-2000
2001-2002
2003-2004
Ogden CL et al. JAMA 2008;299:2401
2005-2006
Changes in Obesity Prevalence by Race/ethnicity, Girls 2-19
Years
Non-Hispanic White
Non-Hispanic Black
Mexican American
50
Percent
40
30
20
10
0
1999-2000
2001-2002
2003-2004
Ogden CL et al. JAMA 2008;299:2401
2005-2006
Changes in Prevalence of Obesity in Men
1999-2008
Prevalence
40
35
30
25
20
15
10
5
0
White
Black
M-A
1999-2000 2001-2002 2003-2004 2005-2006 2007-2008
Year
Flegal KM et al. JAMA 2010;303:235
Changes in Prevalence of Obesity in Women
1999-2008
60
50
40
Prevalence
White
Black
M-A
30
20
10
0
19992000
20012002
20032004
20052006
20072008
Year
Flegal KM et al. JAMA 2010;303:235
Changes in the Prevalence of Adult Obesity:
NHANES II – NHANES – 2007-2008
NHANES II -1999-2000
Men
Women
Men
0.6 %/y
0.7 %/y
1999-2000 – 2007-2008
0.47 %/y
0.21 %/y
2003-2004 – 2007-2008
0.18 %/y
Annual Adult per Capita Cigarette Consumption and Major
Smoking and Health Events – US 1900-1998
Thousands per year
1st World Conference
on smoking and health
Broadcast advertising ban
1st Surgeon
General’s report
1st Great
American smokeout
Nicotine medications
Available over
the counter
End of WW II
Fairness Doctrine
messages on
TV and radio
1st smoking
cancer concern
Nonsmoker’s
rights
movement
begins
1910
1920
1930
1940
Surgeon
General’s
report on
environmental
Tobacco smoke
Federal cigarette
tax doubles
Great Depression
1900
Master
settlement
agreement
1950
Year
1960
1970
1980
1990
1998
Elements Common to Social Movements
Shared and personalized perception of a threat
Common frame
Grass roots commitment
Social network focused on collective action
Local nodes with dense social ties, linked to other
groups with weak bridging ties (rapid diffusion of
innovation)
Organizational structure
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
Sugar drinks (SDs) = 250 Kcal/d
Only 21-50 Kcal/d of calories from SDs consumed in schools
Healthy Weight Commitment – 1.5 trillion Kcal reduction
12.5 Kcal per capita
Quality PE = 35 Kcal/d
Principal Targets for Obesity Prevention and Control
Pregnancy: pre-pregnant weight, weight gain, diabetes,
smoking
Reduce energy intake
Decrease high and increase low ED foods
Increase fruit and vegetable intake
Reduce sugar drinks
Decrease television time
Breastfeeding
Increase energy expenditure
Increase daily physical activity
CDC Perspective
Identification of effective interventions more important than
identification of cause
Focus on population strategies that change the food and physical
activity environments
Interventions aimed at single targets likely less effective than
comprehensive multi-sectoral approaches
Rely on evidence-based practice and practice-based evidence
12
Settings for the Prevention and Treatment of
Obesity
•
•
•
•
•
•
•
Industry
Medical settings
Child care
School
Work site
Community
State
U.S. State Regulations for Obesity Prevention in Child
Care (Benjamin, et al. BMC Public Health 2008; 8:188)
Child Care Centers
(# of states)
Family Child Care
Homes (# of states)
41
34
Limit SSB
7
7
Limit low nutr. foods
9
7
No forcing to eat
32
32
No food as rewards
10
5
Support BF
9
3
Limit screen time
17
15
Required PA
3
3
Indicator
Water freely available
NYCDHMH, Amend Article 47, NYC Health Code;
Applies to Group Day Care in NYC
Television, video and other visual viewing
– Cannot be used for children <2 yo
– Limited 60 minutes per day of educational programs or
programs that actively engage child movement for children
2+ yo
60’ physical activity required
Eliminate sugar drinks
Provide 1% or no-fat milk
Make water freely available
Childhood Obesity Task Force Recommendations
1.6: Early childhood settings should support breastfeeding.
1.9: The AAP guidelines on screen time should be made more available in
early childhood settings.
1.10: The Federal government……should provide clear, actionable guidance
to states…..on how to increase physical activity, improve nutrition and
reduce screen time in early child care settings.
1.11: States should be encouraged to strengthen licensing standards and
Quality Rating and Improvement Systems to support good program
practices regarding nutrition, physical activity and screen time in child
care settings.
1.12: The federal government should look for opportunities in all early
childhood programs it funds (CACFP, Head Start, DoD, etc) to base
policies and practices on current scientific evidence related to child
nutrition and physical activity, and seek to improve access to these
programs
National Initiatives
SG Vision for a Healthy and Fit Nation
Let’s Move
Child Nutrition Reauthorization – Healthy Hunger-free Kids Act
Childhood Obesity Task Force
HHS Healthy Weight Task Force
National Action Plan for Physical Activity
Healthy People 2020
Dietary Guidelines for Americans
Communities Putting Prevention to Work (CPPW)
Surgeon General’s Call to Action on Breastfeeding
FTC Guidelines for Foods Marketed to Children
Affordable Care Act
Pillars of Let’s Move
Goal: End childhood obesity in a generation
Helping parents make healthy choices
Menu labeling
Front of Pack Labeling
Serving healthier foods in schools
Child Nutrition Reauthorization
Accessing healthy affordable food
Healthy Food Financing Initiative
Increasing physical activity
Let’s Move Initiatives
•
•
•
•
•
Let’s Move Outside (Parks and Recreation)
Let’s Move Cities and Towns (n = 470)
Chefs Move to Schools
Let’s Move Salad Bars to Schools
Let’s Move in Indian Country
– Baby Friendly Hospitals by 2012
– Increased access to child nutrition programs
– HUSSC in schools
Child Nutrition Reauthorization
• Nutrition standards for all foods served in schools
• Performance-based reimbursement for compliance with
school meal standards
• Child care: update CACFP standards, free water
available, encourage daily PA and limit media use
• Performance bonus for states that increase % breastfed
infants
• Broadened use of SNAP-Ed funds to address policy and
environmental initiatives
Childhood Obesity Task Force Report
Added “Early Childhood”
Prenatal care
Breastfeeding
Screen time
Early care and education
Chemical exposures
70 recommendations across Early Childhood,
Empowering parents and caregivers, Healthy
food in schools, Access to healthy affordable
food, and Increasing physical activity
National Initiatives
SG Vision for a Healthy and Fit Nation
Let’s Move
Child Nutrition Reauthorization – Healthy Hunger-free Kids Act
Childhood Obesity Task Force
HHS Healthy Weight Task Force
National Action Plan for Physical Activity
Healthy People 2020
Dietary Guidelines for Americans
Communities Putting Prevention to Work (CPPW)
Surgeon General’s Call to Action on Breastfeeding
FTC Guidelines for Foods Marketed to Children
Affordable Care Act
American Recovery and Reinvestment Act
$373m for Communities Putting Prevention to Work (CPPW)
Miami-Dade County: procurement policies in schools,
hospitals, and community institutions
San Antonio: complete streets, schools open after hours
for physical activity
$120m for States, Territories and Tribes for CPPW-STI
Rhode Island: integrate active living into planning
Minnesota: increase schools meeting IOM
recommendations; procurement policies to reduce sodium
and eliminate trans fat
Nutrition Strategies Across All States and
Territories
Physical Activity Strategies Across All States and
Territories
Affordable Care Act. Title IV: Prevention of Chronic
Disease and Improving Public Health
Subtitle A – Modernizing disease prevention and PH systems
• Sec 4001: National Prevention, Health Promotion and Public
Health Council
• Sec 4002: Prevention and public health fund
• Sec 4003: Clinical and community preventive services
Subtitle C – Creating healthier communities
• Sec 4201: Community Transformation Grants
• Sec 4205: Menu labeling
• Sec 4207: Reasonable break time for nursing mothers
Affordable Care Act. Title IV: Prevention of Chronic
Disease and Improving Public Health
Subtitle D – Support for Prevention and Public Health
Innovation
• Sec 4303: CDC and employer-based wellness programs
• Sec 4306: Childhood obesity demonstration project
Elements Common to Social Movements
Shared and personalized perception of a threat
Common frame
Grass roots commitment
Social network focused on collective action
Local nodes with dense social ties, linked to other
groups with weak bridging ties (rapid diffusion of
innovation)
Organizational structure