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Vital Signs Telebriefing: State-Specific Obesity Prevalence Among Adults – United States, 2009

Tuesday, August 3, 2010 – 12:00pm ET

Operator: Welcome, and Thank you for standing by. At this time, all participants are in a listen-only mode. During the question-and-answer session today, you may press star 1 to answer a question. Today's conference is being recorded. At the time, I'll turn the call over to Karen Hunter. You may begin.

Karen Hunter: Hi, Thank you and welcome to today's MMWR Vital Signs telebriefing. Today we're going to be focusing on obesity prevalence, and our speakers today will be Dr. Thomas Frieden, who's the CDC director, and let me spell his last name. It's f-r-i-e-d-e-n. We will also be joined by Dr. Bill Dietz who's the director of CDC's Division of Nutrition, Physical Activity and Obesity. His last name is d-i-e-t-z. And he is an MD, as is Dr. Frieden. And then we also have Heidi Blanck. Her last name is b-l-a-n-c-k. She is the chief of CDC's Obesity Branch, and she will be available to answer any data questions related to the Vital Signs report. So, now I'm going to turn it over to Dr. Thomas Frieden, CDC Director. Dr. Frieden?

Tom Frieden: Thank you very much, and thank you for joining us. As you may recall, CDC Vital Signs is a new report that appears on the first Tuesday of each month as part of the morbidity and mortality weekly report. It's designed to give the latest information on key health indicators. Last month was the first on colon and breast cancer prevention. This month is on obesity. And the future months will be covering tobacco use, access to health care, alcohol, HIV, motor vehicle safety, health care-associated infections, heart health, key pregnancy with infant mortality as well, asthma and food safety. And we thank you for your interest.

Obesity is a major public health problem. We need intensive and ongoing efforts to address obesity or more people will get sick and die from the complications of obesity, such as heart disease, stroke, diabetes and cancer. According to 2009 BRFSS data, which we are releasing today, the number of states where self-reported obesity prevalence is 30% or higher has tripled since 2007 from three states to nine states. Less than a decade ago, in 2000, not a single state had an obesity prevalence of 30% or higher. And although the goal for 2010, through "healthy people 2010," was to have an obesity prevalence of 15% or less, not a single state has achieved that goal. The 2009 BRFSS data show a 1.1 percentage point increase, about 2.4 million additional people self-reporting obesity between 2007 and 2009 among adults aged 18 and over. Not only are the costs of obesity high, and I refer you to the Vital Signs color four-page document which has a graphic which gives some of the information about the impacts of obesity, but in addition, the economic costs are high. In 2008 dollars, medical costs associated with obesity were estimated at $147 billion. That translates into medical costs for people who are obese that were $1,429 higher per person each year compared to normal-weight individuals. Six things can reduce or prevent obesity. The first is increasing physical activity. The second key initiative would be to increase the uptake and continuation of breast feeding, which is healthier both for the infant and the mother. The third is to increase fruit and vegetable intake. The fourth is to reduce screen time, TV time. The fifth is to reduce high-calorie food intake, and in particular, to reduce intake of sugary drinks, making healthier options, such as water. In the fact sheet, you will see the list of what can be done.

Obesity is a societal problem and it will take a societal response. There is information in the materials on what the federal government's doing, what states, local governments, communities and individuals can do. Efforts include, in particular, the "let's move" campaign of the first lady, which is particularly important because it involves all of society in things that everyone can do in key sectors of society. Second, the communities putting prevention to work initiative, which promotes change at the community level. Third, childhood obesity task force that is addressing these issues throughout the federal government as some examples. At the state, municipal and community level, there can be initiatives through zoning or incentives to provide supermarkets and farmers markets in low-income areas and food deserts. It's hard for people to eat healthy when there isn't healthy food accessible to them. Expand programs that provide fruits and vegetables to schools, hospitals and communities. Support hospital programs to promote breast feeding. There are far too few baby-friendly hospitals in this country. Adopt policies that promote bicycling, walking and active transportation as well as public transportation. The community can also promote safe routes to schools, promoting walking and cycling, improve the nutritional quality of all food available in schools, daycares, hospitals and public buildings, make water freely available as an integral part of all meals at schools and daycares, at least, and increase the proportion of active time during physical education classes. Studies in the past have found that although kids don't get enough time in physical education classes, even the time they do spend is often not as well spent as possible in assuring that kids are very active during whatever time they have is something that every community can do without changing their curriculum as well as increasing the amount of time in physical education programs. So, I'll stop here and turn it over to Dr. Dietz and then we'll be available for questions briefly.

Karen Hunter: Thank you, Dr. Frieden. And now we'll hear from Dr. Bill Dietz.

Bill Dietz: Thanks, Dr. Frieden. Just to amplify a few comments that Dr. Frieden made. In 2007, there were only three states that had an increased prevalence of obesity above 30%. Those states were Tennessee, Alabama and Mississippi. In the 2009 behavioral risk factor surveillance system, the states that exceeded the 30% mark were Missouri, Kentucky, West Virginia, Tennessee, Arkansas, Oklahoma, Louisiana and, again, Mississippi and Alabama. The Behavioral Risk Factors Surveillance System (BRFSS) and the National Health and Nutrition Examination Survey (NHANES) are two distinct surveillance systems based on different data sources and used for different purposes. The BRFSS is a telephone survey, the largest in the world, conducted of adults aged 18 and over by health state department. And these surveys, the Behavioral Risk Factor Surveillance System, provides us with state-based data which states can use to plan their interventions and assess their progress. The BRFSS obesity estimates are always lower than the overall obesity prevalence estimates from the national health and nutrition examination survey. So that for example, nationwide in BRFSS, the prevalence is 26.7% in 2009 versus 33.9%. The prevalence of overweight in these two surveys is more comparable and BRFSS, it's 32.6% and in NHANES, it's 34.4%. Reason for these differences is, as tom indicated, is that the behavioral risk factor surveillance system data are self-reported, whereas in NHANES, participants are weighed and measured. In addition, the NHANES goes beyond the BRFSS with more intensive health and status measures, but it does not provide state-level data and is best used to measure the national rate of obesity and the diseased burden associated with it. Both the behavioral risk factor surveillance system and NHANES highlight the proportionate impact of obesity on some populations. In both, the highest prevalence is among non-Hispanic blacks, and particularly, non-Hispanic black women, followed by Hispanics, and in turn, followed by Caucasians. In addition, as the current data indicate and the math in the Vital Signs indicates, some regions of the country are disproportionately affected, particularly the South and the Midwest, as you gathered from the states that I listed. As Dr. Frieden emphasized, obesity is common, serious and costly, affects virtually every system in the adult body. And as he indicated, the challenge is how do we begin to start driving these obesity numbers downward and start reversing this trend? And we believe that like the successes with tobacco, investments in policy, environment and systems changes, like those which he mentioned, are going to be necessary to prevent and control the epidemic. Those policy initiatives may not be especially effective for the seriously obese, but the strategies which he outlined are likely to promote health at any weight. So, I think I'll stop there and open for questions.

Karen Hunter: Thanks, Dr. Dietz. And I think we're ready to take some questions now.

Operator: Thank you. We will now begin the question-and-answer session. If you would like to ask a question, please press star 1. Please unmute your phone and record your name clearly. Again, press star 1 to ask a question. And one moment for our first question. And our first question comes from Mike Stobbe at the Associated Press, you may ask your question.

Mike Stobbe: Hi. Thank you for taking the question. Kind of a two-part question. The first is, doctors, could you describe the trajectory of the problem? Is it escalating or is it kind of leveling off a little bit? Could you kind of put it in some historical context what we're seeing? And also, part two is about – we've already seen some initiatives to try to address the obesity problem. Have any of those succeeded? Is there any data you can discuss about things that have worked?

Tom Frieden: I'll start with the answer and ask Dr. Dietz to continue. So, big picture is that over the past several decades, obesity has increased faster than anyone could have imagined it would. Obesity has doubled in adults and tripled in children. It's little too early to say exactly what the trends are over recent years, and certainly, recent initiatives that are just announced we wouldn't expect to see a result in this short a period of time. The data from n NHANES, which includes actually weighing people, suggests that there may be a leveling off of the increase. That doesn't suggest that the problem is over. It would kind of be like saying if two-thirds of your town is under water and the water's not rising anymore, that doesn't mean the problem is not severe. For the BRFSS data, the trend looks like it's continued to increase. What BRFSS provides, as Dr. Dietz mentioned, is a state-specific level, which is not available through n NHANES and information over time. So, the exact trends are hard to definitively pinpoint, but what we can say is that this is a large problem, it's widespread throughout the U.S., and the number of people self-reporting height and weight that puts them in the obese category has continued to increase between 2007 and 2009. There has been progress in some of the initiatives in terms of getting healthier foods into schools, and Dr. Dietz can speak to that. There has not yet been an example of widespread, statewide change to reduce the prevalence of overweight or obesity. Dr. Dietz?

Bill Dietz: Yes, thanks. The school health policies that Dr. Frieden alluded to that were published last fall by the division of adolescent and school health showed very substantial changes within the schools with respect to the availability of high-calorie items. Those had substantially decreased. And as Dr. Frieden indicated, we don't have good evidence of population-based changes in the adult population. However, as you probably know, in Arkansas, there have been efforts under way for a while that began about four or five years ago with universal screening of DMI of children in schools, and that was accompanied by a variety of interventions, both within schools, within the school food services and within education of physicians and efforts from the department of health in Arkansas, which led to a modest decrease in obesity. It first plateaued and then actually decreased by about 0.5% in a year, and I haven't seen any more recent data. But that example, I think, demonstrates that a multisectoral effort at the state level has had some success in the prevention and control of childhood obesity. But as I said, I don't think we have data yet from adults that we report on here in the BRFSS that show a comparable shift.

Karen Hunter: Next question, please.

Operator: Thank you. Our next question comes from Denise Grady with the New York Times, you may ask your question.

Denise Grady: Thanks very much. Since there seems to be such a huge difference between Colorado and other states that have very high numbers – I mean, Colorado's almost half of what Mississippi has – does anybody know why, what's going on in Colorado? Is this real? Is anybody trying to study it and find out what the difference is there? And then I'd like to ask if you know where we stand internationally in terms of obesity? Thanks.

Bill Dietz: Dr. Frieden, would you like me to answer that question?

Tom Frieden: Yes, please go ahead.

Bill Dietz: Okay. We don't know why Colorado differs from other states. We've looked in a crude fashion at some of the other measures within the behavioral risk factor surveillance system, and they don't show lots of differences, but I have some assumptions or biases about it. Two-thirds of Colorado live in Denver, which as you know is the mile high city. And we do know that people who live at altitude have to spend more energy on a daily basis in terms of their cardio-respiratory effects just to breathe and even physical activity requires more energy. So, from the individual point of view or the metabolic point of view, altitude may be one partial explanation. The other is that for years, Colorado has invested its state lottery funds in infrastructure to support physical activity. So, a lot – if you go to Denver and outside of Denver, there are bike trails, walking trails, and they're heavily used, suggesting that Colorado has more of a culture of physical activity than other states. The harder question is why the District of Columbia falls into this less than 20% category, because as you know, like most of the south, it has a large African-American population. Some of those eating habits may be changed. And yet, Washington has a lower prevalence. And perhaps it's because so many people in Washington rely on the metro, and we know that people who use public transportation use more energy. But those are postulates. We don't really understand those differences, but it's an important activity. The other thing that we do know a little bit more about in d.c. is that there are higher rates of breast-feeding and higher rates of fruit and vegetable intake that came from BRFSS, which may suggest other reasons for why D.C. is lower. With respect to your question about internationally, we are one of the heaviest countries, but I've seen some data that suggests that we're not the heaviest. Some of the Middle Eastern countries, particularly among women, may have a high prevalence. But I should add that every country that has looked at data over time is showing an increase in obesity. There does seem to be some flattening in the U.K., but as I said, that's in kids. And every other country has shown an increase in prevalence over time just like we've seen here.

Tom Frieden: I would just add to that that monitoring systems in other countries are not always as extensive as the monitoring systems that we have here, so we have more information about the U.S. and about some other parts of the world, but we do – every piece of information we've seen suggests that the obesity epidemic is a global epidemic, and even in developing countries we're seeing obesity and diabetes increasing at very rapid rates. And Denise, as you may recall, in New York City, Manhattan has a much lower level of obesity than the other boroughs, and that is even after correcting for socioeconomic status. And there are various theories that might explain that – public transportation, as Dr. Dietz mentioned, is certainly one of them.

Karen Hunter: Thank you. Next question, please.

Operator: Thank you. And this question comes from Patricia Neigmond with NPR. You may ask your question.

Patricia Neigmond: Hi. Thank you for taking the question. I'd like you to just elaborate a little bit on the states. I was interested in Arkansas making something of a difference in obesity rates in the schools. Do you know what other states actually have made policy changes in terms of getting healthier lunches in and vending machine changes in the schools? And also, do you have any sense of what the PE activity level is in schools at this point and if there's any significant changes that are increasing physical activity? And the reason I'm asking this is because of what the data that you had mentioned that suggests a stalling in the rate of increases of the epidemic, at least among children and adolescents.

Tom Frieden: I'll make one comment and then let Dr. Dietz complete it, and I'll only be on the call for one more question after this. The national data suggests that – and we can get you more detailed data both nationally and by state – but that not only do kids not have enough time in physical education classes, but even during the time that they're in the physical education classes, they're only physically active about a third of the time on average. With good programming, teacher education, monitoring, that number can go up to at least half or more of the time active in physical education classes, and that's something that doesn't cost any money to do and can make a big difference. So, there has been some improvements, but we have much further to go in terms of school and community-based policies. Dr. Dietz?

Bill Dietz: With respect to other good examples of schools or states that are doing things in schools, I read yesterday that Massachusetts had initiated very substantial changes in schools throughout the state. I don't have the details, but I would refer you to them. Among other things, I think they substantially reduce fast foods and fried foods and increased the availability of fruits and vegetables. Dr. Frieden mentioned earlier the communities putting prevention to work and the states putting prevention to work. And one of the important strategies that states are employing around food access is both increasing the availability of healthy food and drink in schools and other public venues as well as limiting the availability of unhealthy foods and beverages. And there's been quite a bit of progress, as I mentioned earlier, across the country in getting sugar drinks out of schools. But in terms of sugar drink consumption, the amount of sugar drinks that kids consumed in schools was small compared to their total sugar drink consumption. All of this is to say that we can point to some of these individual changes, but any single change by itself is not going to make the difference. As Dr. Frieden emphasized, these efforts need to be multisectoral in nature and complimentary so that you can't expect improved counseling in medical settings to work unless people have choices to make in their communities around physical activity or better diet.

Karen Hunter: Next question, please.

Operator: Thank you. Next question comes from Katherine Hobson with the Wall Street Journal, you may ask your question.

Katherine Hobson: Hi, thanks. I just have a question about this data, this BRFSS. Is this brand new? Because there was a study, a very similar report out from Trust for America's Health and the Robert Wood Johnson Foundation in the last couple months that seems to be based on the same data, and yet, from my quick read, seems to have slightly different rates for the states. Can you clear that up?

Bill Dietz: Sure. Thanks for that question. We do these analyses of state prevalence rates on an annual basis, and the analysis that we use is different than that which Trust for America's Health uses. They use a rolling average of three years, whereas we use a year-by-year assessment, and that's why the estimates of prevalence are different in the report from those which we're publishing in the Vital Signs.

Karen Hunter: Next question, please.

Tom Frieden: I would just add to that, and I'll have to sign off after this, that many of us who do public health surveillance didn't think it was worthwhile to ask height and weight every year or even every other year because we didn't think they would change that much. But in fact, they've been changing so quickly that every year or every other year we've been able to see, unfortunately, statistically significant increases at the state and national and sometimes community level in the rate of obesity.

Karen Hunter: Okay, Thank you, Dr. Frieden. And I believe Dr. Frieden has another commitment, but we will take the next question for Dr. Dietz.

Operator: Thank you. The next question comes from Stacy Singer with the Palm Beach Post, you may go ahead and ask your question.

Stacy Singer: Hi, Thank you. I guess I wondered if you could talk a little bit about the affordable care act and some of the provisions in there, like wellness, incentives and calorie counts on restaurant menus and whether you think those may or may not make a dent and why? And also, i'd ask the question whether it might now be time to talk about taxing unhealthy foods? Thanks.

Tom Frieden: With respect to health reform, one of the most important pieces, or I should say an important piece, is the menu labeling, which you alluded to. As you know, this was in place in three states and 10 or 12 other jurisdictions, but was not likely to occur in a lot of other states until it became part of health reform. And this is an important step to give people a sense of what they're going to be buying in restaurants that I think it's set at 20 chains or 20 restaurants or more so that they'll at least be able to make an informed choice. It may not change their choice, although some preliminary data from New York suggests that it may not only change some people's choices, but also may prompt reformulation of products by those restaurants. The other important – another important piece of health reform that comes to what may happen in medical settings is that measurements of height and weight are now part of the electronic health records, and that's one of the core measures, and that's likely to prompt more counseling by providers who we know do not recognize obesity, or at least don't put it in the chart. And even when they have obese patients, even if they note a patient's BMI, they are less likely to counsel. And with obesity being a societal problem as well as health problem, engaging providers in those initiatives is important. And then the final point is, as never before, this legislation invests in prevention and wellness. And how that plays out in terms of programmatic efforts is still under pretty intense discussion, but it's fair to say, as Dr. Frieden emphasized at the beginning, that there's never been a greater convergence of energy or interest in the problem of obesity with the "let's move" initiative, the president's childhood obesity task force, the work of HHS and the communities putting prevention to work.

Operator: Thank you. Our next question comes from Ana Radelat with Capital News Connection, you may ask your question.

Ana Radelat: Hi it was asked before, but I'm not sure it was answered completely. What – this seems to be – I know that it mentioned Middle Eastern countries and some other exceptions where obesity rates are rising. Middle Eastern countries, of course, women are not allowed to move around in many cases much – go to the gym, participate in sports, if you can figure that one out. But this obesity thing seems to be a real American problem, and I'm wondering if anybody, you know, has determined what, you know, what particular in our culture leads to this? And the other question is, I'm looking at the chart and I know that minorities have higher rates, and there's a socioeconomic aspect of obesity. But some states that have increased sharply – I'm talking Missouri and Iowa, some of the Midwestern states that don't have high rates of minorities have had increases in obesity. Was age looked at at all? We talk a lot about children, but you know, people tend to gain pounds as they hit middle age, and many populations are getting older. Was age factored into this? I appreciate it.

Bill Dietz: Yes. So, you've asked about four questions, so let me start with the last one first. The prevalence of obesity increases with age in both men and women, so that in the 18 to 29-year-old age group, the prevalence is about 20%. In the 60 to 69-year-old age group, the prevalence is about 30%, roughly, 30%, 31%. That's in a table in the MMWR. Your question about other countries – this is not uniquely an American problem. I think that we have a very high prevalence, but a couple years ago, I compared the rate of rise of obesity in women in the U.K. versus women in the united states, and the curves were parallel. To your question about what leads to this, my answer is everything. That there have been multiple changes in the food environment, multiple changes in the physical activity environment, and I don't think that we can ascribe the increase in prevalence to anything other than a broad cultural shift that has made high-calorie food more readily available and reduced opportunities for physical activity. Your fourth question was why minorities have higher rates, and you suggested that it was due to socioeconomic status. In fact, when you look carefully at socioeconomic status, it is very confusing because there is no consistent pattern among men or women or socioeconomic groups. The most consistent finding over time seems to be an inverse relationship among white women, but you don't see comparable shifts or association in any other ethnic group. Men are different. Women are different. It's just – it's too facile an explanation. That's not to say there aren't important cultural or ethnic-specific factors. So, for example, among children, we know that Hispanic boys have a higher prevalence than other boys, whereas among African-American children, African-American girls have a higher prevalence. That's not due probably to genetics, it's not due to environment. It's probably due to parenting practices that are ethnic-specific. We also know that in inner city neighborhoods, which may be predominantly populated by minorities, that there are food deserts, that people don't have the same access to fresh fruits and vegetables or other healthful foods that they do in other settings. And those neighborhoods are also full of fast-food restaurants and liquor stores. So, there are associated with the ethnic disparities, there are both cultural differences as well as neighborhood-specific differences, which may be contributing to these disparities.

Karen Hunter: Thank you. And I think we have time for two more questions. So, we'll take our next question.

Operator: Our next question comes from Jane Norman with Congressional Quarterly, you may ask your question.

Jane Norman: Yeah, hi. Thanks for taking my question. As we've seen in many of these reports, the south is a problem area for these obesity rates rising, but this report also includes Missouri, which is more of a border state, going into the Midwest. What is the next region that concerns you in terms of the increase in obesity? Is it the Midwest, southwest? What do you see when you look at a map?

Bill Dietz: You're asking me to look into a crystal ball that I don't have, but I would say that other states, rural states, I think, are also important. If you look at this map, many of those states are rural. They're not as rural as Nebraska or Montana, but the rural issues are particularly important again because of access to both grocery stores and opportunities for physical activity. I think we continue to be concerned about the disparities that exist in minority populations. So, other states with substantial minority populations, again, the southern states which are part of the heart disease and stroke belt as well as diabetes, are at particular risk. So, you know, I think as the CPPW has kicked in, we're now beginning to address nutrition and physical activity in all states with a particular – some states are spending more money on that than others, but I think this is still a countrywide problem, and we have to think of it in those terms, although the solutions may be state-based and local.

Karen Hunter: Thank you. And we'll take our final question now.

Operator: Thank you. Our last question comes from Kathy Dohney with WebMD. You may ask your question.

Kathy Dohney: Thank you. I'll be quick. The newspaper says 2006 medical costs associated with obesity were as much as $37 billion, but $1,400 higher than persons of normal weight. I'm assuming that's annual? And then is there any way to determine how much of is that is out of pocket, trying to bring this down to the personal level?

Bill Dietz: Yes, you're correct that the $1,400 a year is an annual cost, and we don't know what the out-of-pocket expenses are. These costs were derived from the national health interview survey and some other national surveys that allowed us to attach costs to obesity, but they're only costs that medical groups have reported, not out-of-pocket. We know, on the other hand, that there is a huge industry for which people pay that has to do with lower-calorie products and opportunities for physical activity. It's a sound point, and I think we need to spend little more time looking at what those out-of-pocket costs are.

Karen Hunter: Okay. Thank you. A transcript of this telebriefing will be available later today on CDC's newsroom site, and that address is www.CDC.gov/media. So, be looking for that in a couple of hours. And this will conclude today's telebriefing. Thanks for joining us.

Operator: Thank you. And this does complete today's conference. We thank you for your participation. At this time, you may disconnect your line.

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