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Telebriefing Transcript
Overweight and Obesity: Clearing the Confusion

June 2, 2005

DR. GERBERDING: Good afternoon. I especially want to thank my CDC colleagues who are here to support us in this effort and our guests.

We have some special experts who will be contributing to this media briefing today.

We're here today to clear up some confusion around the relationship between obesity and overweight to the negative health consequences that we all know are associated.

We're going to focus first of all on what we actually know about these problems, then what we don't know, but need to find out, and finally--and I think most importantly--what are we doing about the problem.

But first let me just review why there's been confusion about the relationship between obesity and overweight and adverse health events.

CDC and other scientists have published several papers describing the association between obesity, overweight and death in our country. We can't get accurate estimates of the association because obesity is not listed on death records, so we have to use methods that rely on extrapolations. The studies that have been done have used different methods and different sources of information, and they've come to some different conclusions so what we've needed to do is to get the scientists in the room and straighten this out.

One of the things that's happened today is that the Institute of Medicine has released information from a symposium of scientists that came together to try to understand what does CDC need to do to improve these methods and how can we improve the science so that we have more accurate information.

They go into a couple of things in that process. One is that we need better methods, and we need to invest more resources in obtaining them, and we have made a commitment as an agency to fund that research with extramural partners.

But we also need to translate our science more effectively so that we avoid this kind of communication in the future, and we are taking steps to do that all as well.

But what we don't want is for this debate to continue to confuse people. We need to be absolutely explicitly clear about one thing: obesity and overweight are critically important health threats in this country. They have many adverse consequences, and let me just give some very specific facts that we do know.

First of all, we know that over the last 20 years, the rates of obesity and overweight in this country have soared astronomically. This graphic depicts the current profile of obesity among adults in the United States, and, as you can see, there are some states where more than 25 percent of the population is obese. Overall, in our country, 65 percent of adults are overweight, and about 30 percent of adults overall meet the criteria for obesity.

To me, even more frightening than that is the fact that 16 percent of the children in this country are obese. That number has increased by at least two times over the last 20 years.

We know that obesity and overweight are important health threats. People who are obese experience an increased rate of hypertension, diabetes, renal failure. They're at increased risk for cancers, including colon cancer, post-menopausal breast cancer, gall bladder cancer, and uterine cancer.

People who are obese and overweight have an increased risk of arthritis and mobility problems. People have sleep disturbances and breathing problems.

Another very scary fact for children--Type II Diabetes, which used to be known as adult onset diabetes, is now increasingly being diagnosed and adding to the cardiovascular risk profile of our children. We have many children now who are not only overweight, but they also have high blood pressure, lipid abnormalities, and diabetes--all of the factors that increase the risk among adults for cardiovascular disease and stroke.

We also know that obesity is linked to problems with child bearing, premature birth, learning disabilities, and other adverse outcomes for infants.

And finally, the economic estimates of the impact of obesity are astronomical. Approximately $52 billion are attributed to obesity in 1995, and by 2003, this figure had increased to $75 billion.

So we're dealing with a health threat that affects people at every stage of life. It is multi-dimensional in its impact, and it costs money.

So that's what we know.

What we don't know yet is the best methods for estimating the impact of obesity on death. And we are committed to learning more about that process, but you can expect that more studies will be coming forward and that more information will be made available as this research is conducted.

We also don't know what the long-term consequences of the obesity epidemic among our children will ultimately be on the health profile of our nation. As these children age and these health consequences accumulate, we may be seeing a very different profile of health status in our country, and that's a very, very worrisome outlook if we don't take steps now to fix it.

But we also unfortunately don't yet know the best way to support Americans who want to sustain weight loss for a long period of time. There are many ideas and many fads, but the science that really helps understand the very best strategies for sustained weight loss are remaining to be conducted.

So let me now focus on what are we doing about this. CDC is taking a number of actions, but our most important action starts with the science. And, again, today, the Institute of Medicine report on methods to estimate the association of obesity and death was released. This is available on the Internet. I think it is a very beautiful summary, not only of the state of the science, but a roadmap for some of the things that we as an agency need to do to improve our science and our communication about these important health threats, and we are taking it seriously, and we have already committed resources, as I said, to do this kind of research.

Second, at the new CDC, we are engaging the entire agency in the development of our strategies around obesity. More than 15 programs and divisions have come together to create what we're calling trailblazer goals for obesity. These goals reflect our research needs. They reflect our program needs, and they reflect our communication needs. And we have committed resources to help implement this new trailblazing goal process that really takes the best and the brightest across CDC and engages them collaboratively up front in tackling this very, very important health problem.

Another component of the new CDC is that we're learning to adopt some of the methods that we have used for outbreak investigations and apply them to obesity. For example, one of our states has requested CDC's assistance in investigating the growing problem of obesity in the states. That's something that we do, for example, with meningitis or West Nile fever. Now, we're applying exactly the same strategy to understanding the determinants of obesity at the state level.

This is the first time this has ever happened in the history of CDC that we have utilized this mechanism for a chronic disease, so we're very interested in following that through.

Another component of the new CDC is our health protection research agenda. And we have worked very hard through the trailblazing goal process to identify not only what are the critical research needs to understand the relationship between obesity and death, but also what are the critical research needs to help us do a better job of preventing obesity or decreasing its complications down the road.

Another component of the new CDC is, of course, our National Center for Health Marketing, which is the place where we will be able to apply state of the art communications strategies so that we not only avoid confusing the public but also we use the very best science and the very best methods available to help people get the information they need to make healthy choices about diet and exercise and other preventable causes of ill health.

I would like to at this time introduce my colleague, Dr. Donna Stroup, who is the Director of the Coordinating Center for Health Promotion and she's going to give you some very specific examples of the programmatic research and implementation strategies that CDC is undertaking in the near future.

Dr. Stroup.

DR. STROUP: Thank you, Dr. Gerberding. It's a pleasure to be with you this afternoon to talk a little bit more about CDC's response to the obesity issue. Dr. Gerberding mentioned the new way in which CDC is working as a result of the futures initiative which she has led during her tenure here.

The obesity trailblazer team is an example of that. The executive leadership of CDC has made a determination to redirect attention and redirect resources around the issue of obesity, to call people from across the agency, just not in the chronic disease arena where this activity resides organizationally, but really across CDC to work in a different way with each other and with our public health partners.

So through this effort we will be engaging new partners such as urban planners to look at the ways in which built environments can influence physical activity. We will be looking at the research gaps that Dr. Gerberding has mentioned and an early outcome of this obesity trailblazer team will identify important research areas, not only in terms of intervention and prevention but the long-term issues. What happens to these obese children as they age and acquire chronic diseases in childhood that used to appear only in older adults?

And we're also interested in interventions in sectors. What works in schools to get kids physically active and to help them make healthy choices around their nutrition.

What works at work sites to help people be physically active on the job? What works in clinicians' offices?

So those are some examples of the kind of research activities. We were very excited to send our disease detectives, as Dr. Gerberding mentioned, to West Virginia earlier this year.

This is a team of public health professionals from CDC that are dispatched for West Nile virus and for meningitis throughout our history.

But this is the first time we've dispatched a team of disease detectives around the problem of obesity, and it was a recognition in one of our states, that their obesity problem was very large and they needed help assessing the readiness of the state and the environmental agencies there to combat it.

In addition to these urgent responses, we are also committed to ongoing collaboration with states and communities around interventions that work, and toward that end I'm very pleased to introduce one of our colleagues from here into DeKalb County, which is where CDC resides, and where many of us live, so this is our DeKalb County physician with us today.

Dr. Elizabeth Ford-Bouchellion has trained at Stanford University, Howard University College of Medicine in Washington, and Howard University Graduate School of Business in Washington, D.C.

She spent some time in the Florida State Health Department before joining the DeKalb County board of health as the district health director, and I'm very pleased to introduce Dr. Bouchellion to tell you a little bit about her experience with our Steps program, Steps to a Healthier U.S., which is a community-based intervention program which includes an evaluation, so that we really know whether these interventions work.

Dr. Bouchellion.

DR. BOUCHELLION: Thank you, Dr. Stroup.

We, at DeKalb County, are thrilled to be recipients of the Steps grant. We are delighted to be participating in this project, we're grateful for the opportunity to reach the children and the adults in DeKalb County, and let them know what our message is about healthy behaviors, healthy lifestyles. As a pediatrician and as a parent of a small child myself, I recognize how important it is to instill good habits and healthy behaviors early, and that's part of what we're trying to do with Steps grant.

Our main job is to encourage healthy lifestyles and change behaviors, and as everyone knows, that's one of the most difficult jobs you have.

Why is this important? Well, here in DeKalb County, we evaluated one of the us (unintelligible) and those children had a body mass index of greater than 30--sorry--34 percent of them had a body mass index of greater than 85 percentile. So obesity is a huge problem, not only in DeKalb County but throughout the United States and Steps grants are one way that we can try to impact that.

I think that we are doing some great things in DeKalb County. We have some wonderful success stories. I'd like to share with you maybe one or two.

We have a young lady in DeKalb who works with Children 's Health Care of Atlanta. She was at risk for type 2 diabetes, as Dr. Gerberding had mentioned earlier, and through the Steps program she was able to learn some healthy behaviors, substituting some of her favorite foods, chips, for example, for bananas instead, and learn something very simple. Dancing. Learn that dancing is a great exercise.

And that's really what we're trying to impact these folks, is to let them know that the things that you do throughout your average day are things that are healthy.

Taking the stairs instead of taking the elevator. Water instead of juice or soda. And so that's what the Steps grant is all about, is using the community, using resources throughout the neighboring areas, using our faith-based organizations and our schools to help promote healthy lifestyles, grade activities, changes in behavior. And that's what we're all about and we are so excited to be a part of this grant.

We'd like to thank Dr. Gerberding and Secretary Mike Leavitt for their support and we look forward to more collaborations in the future. Thanks.

DR. GERBERDING: Thank you for that. It's invigorating to hear a success story now and then. Before we take questions, I just want to emphasize one more time why we're here today. That was to take another step toward clearing up the confusion around the association between obesity and overweight as important causes of ill health in this country. We will continue to focus on our science, we will continue to focus on the kinds of programs that are ongoing at the community level in all different environments, and we will of course continue to work on improving our communications so that we take the science that we have at CDC and provide it to the public in a way that allows them the best change to make healthy decisions.

In the context of obesity and overweight, that means more exercise, fewer calories, and really taking the steps to be healthy.

So let me take some questions.

MODERATOR: Thank you. Our first question comes from Miriam Falco from CNN. You may ask your question.

QUESTION: Hi, Dr. Gerberding. I guess the question that people may have based on the confusion is do you still stand by the statement that there's an obesity epidemic in this country?

And also if we've got a lot of information either from this group that went to West Virginia, and these already in place programs, how much research needs to be done or how long will it take for answers to be accumulated, and how many more kids will be getting, and people will be getting more obese in the meantime?

DR. GERBERDING: With respect to your first question, in my opinion there is an epidemic of obesity in this country and let me just give you one graphic that illustrates that.

Here, on this slide, where we're showing the picture of obesity in 2003, we can compare that with the picture from just a decade and a half ago, 1995, I believe, where you can see--or 1990--where you can see that there was much less obesity in the United States. The blue states are states where the prevalence was 10 to 14 percent, and the light-blue states are states where the prevalence was less than 10 percent.

So if you compare these two pictures, I think you can see that we have had a dramatic increase in the proportion of people in our world that have obesity. That constitutes, in my view, a serious epidemic. I don't think it's overstating the problem to make that claim and I think it lends credence to the approach that the new CDC is taking in terms of applying some of the methods that we've used for more time-compressed health problems to one that, while it may be happening over a longer period of time, it's at least as important, if not more important in its overall health consequences to our citizens.

I think using the term epidemic reminds people that we have to take this threat very seriously. While we may not have an accurate estimate yet of the exact number of people who died from obesity, we certainly know that there's a large number of people who have the problem.

We know there's an even greater number of people who are moving in the direction and we know that harmful health effects are increasingly present in our society.

Your second question about the investigation of obesity in the state, and do we need to know more, do we need to know more research to really effectively combat this problem? I think, again, at CDC, we like to start from the scientific framework when we solve problems.

As disease investigators go out and understand the associations of obesity at the community level, they're going to learn new things.

They're going to learn about how the factors work in specific groups of people and people of specific ages. We know that obesity is one of those areas that is plagued by health disparities.

There's a much higher rate of obesity among African Americans and among Hispanics in the United States. There's also a much higher proportion of people who are native Americans, who have problems with overweight and obesity.

So we will have a more precise understanding of the causes of obesity and that hopefully will allow us to understand, first and foremost, how to communicate more effectively when we do have information that can help people motivate changes or communities to take steps to lower obesity rates. But also it will help us inform and expand our overall capacity and research agenda, so that we can take those lessons learned and apply them more efficiently and economically elsewhere.

Let me take a question here from the room.

QUESTION: Hi. Thank you. David Wahlberg from the Atlanta Journal-Constitution. In journalist fashion, I'll try to sneak in two questions.

DR. GERBERDING: Well, Miriam always gets to, so we'll let you also.

QUESTION: Okay. The first one is I note today you're focusing on the morbidity and cost related to obesity and saying that the science is still relatively immature on estimating the preventable deaths from obesity. But if the science is immature, why was so much made of last year's study of 365,000 deaths and the fact that that was about to eclipse the deaths from smoking?

My second question is the latest study talked about how being overweight may actually be beneficial as opposed to harmful and that's caused a lot of confusion among the public. Is that true?

DR. GERBERDING: Let me take your first question and thank you for asking that.

It's important to remember that the first study actually was a study based on 1990 data, so the study that CDC published last year was an apples to apples comparison of information collected in 1990 and then repeated from data obtained in the year 2000.

When the first study was published in 1990, interestingly, it showed that of the most important preventable cause of death in the United States was tobacco use and that overweight and nutrition were second preventable components of death. There was very little controversy around that paper.

People accepted that information and there was not questioning of the methodology or really attention at all to the scientific method.

So when CDC made the decision to update the paper in 2000, using basically the same method, we were not prepared for the dispute that the new results would demonstrate.

The results of the more recent study show that tobacco was the leading cause of death in a preventable basis in this country, and I think that's a very important message not to lose sight of. Tobacco, tobacco, tobacco.

But you don't actually have to be a scientist to appreciate that as the rates of tobacco are declining and hopefully we'll be able to sustain those rates of decline, although we are worried because in recent years there's been a reduction in the rate of decline.

But if we see less tobacco and we see obesity going up, which we very clearly are seeing in our country, that after some period of time one is going to catch up with the other, and, you know, I hope that doesn't happen.

What we would like is for both of these preventable factors to disappear but until we find interventions that truly can get us to that place where we have a minimization of preventable risk, we are very much going to need to focus on both of these health hazards, not just among adults but also among children who are moving into the age strata where those risks can emerge.

Your second question about the relationship of overweight and bad health outcomes, in the more recent study, there was a statistical suggestion that people who were modestly overweight were at lower risk of death.

But I think when you talk to the investigator, and I would encourage you to do that, there are some statistical aspects of the way the study was designed and the data sources used in that, that the author herself would not claim that overweight as protective of ill health.

So we want to be very clear--obesity and overweight--and I'm sorry to say overweight because I know a lot of people were hoping that CDC was going to come out and say it was okay to be overweight but we're not saying that. It is not okay to be overweight.

People need to be fit ,they need to have a healthy diet, and they need to exercise and overweight is a very important health issue in and of itself, but also overweight is a major predictor of future obesity. It's a lot easier to get back into a fixed state if you're starting from a point of being overweight than it is if you wait until you're already obese.

So we would emphasize that overweight is a health problem and that people need to understand that it is relevant to their personal health as well as to the health of their children and their families and we hope at CDC that we'll be able in the future to provide better science and better strategies to help combat that problem.

Let me take a phone question, please.

OPERATOR: Thank you. Marilyn Marchione, from Associated Press, your line is open.

QUESTION: Hi. Thank you very much, doctor, for taking this. I wonder if you could clarify a little bit more what you just said about the overweight point. I'm wondering specifically are you backing off or looking at all of the methods that were used in this most recent analysis now that a number of scientists have called into question the findings of this report?

DR. GERBERDING: I think first of all what we want to do is make sure that what we're focusing on here is not the controversies that scientists create amongst themselves when they debate the appropriate methodology or the appropriate data sources. As the IOM was very clear to point out today, this risk estimation process is in its infancy, and we have a lot to learn about the best kinds of study designs. And the other thing to appreciate--that this is not static. One of the good things that's happened in the last few years is that some of our health care strategies have improved so that the mortality rate from cardiovascular disease and stroke have declined somewhat because of treatment.

So if all other things were equal, we would be seeing a reduction in the impact of obesity, because the treatment has improved. So for at least a period of time, it would disguise the true effect of obesity on health status. All this means that the numbers are going to change and the methodology is going to evolve over time, and we would like it to evolve as quickly as possible, but it took about 40 years for us to get reliable estimates of the relationship between tobacco and death. And we are still not done with that job.

So we have to got to reassure the public that the scientists are doing their job. Controversy in science is part of the process. We encourage that. We don't want people to artificially hide controversies. We want to get them out in the open. But we do need to do a better job of communicating about those controversies so that we don't end up with a confused public. I'm very sorry for the confusion that these scientific discussions have had. We recognize in retrospect that we needed to do a much better job of thinking not just about our scientific message, but also about our public message as these studies emerge from various parts of CDC, and that we're not the only agency doing studies.

There are academicians across the country who are working on this problem. We hope more people will be working on it. But we kind of need your help as well to let us know when our message is not coming across clearly to you, and we will use our new resources in our national center of health marketing. We're just finalizing the recruitment of a new director for that center, so we expect that we will be out in front of this issue in the future.

I'll take another question from the telephone, please.

OPERATOR: Thank you. Eric Berger, from the Houston Chronicle, your line is open.

QUESTION: Thank you, Dr. Gerberding. I've got a couple questions.

First of all, so the message that you want to clearly send is that overweight people today are still living unhealthy lives and that comes even in light of the recent study and then one by David Allison a year or two ago about years of life loss, which showed very little risk for overweight people and even some negative trends for minorities.

And then the second question is I'm just curious about the size of the obesity research as a part of the CDC budget.

DR. GERBERDING: Thank you. Again, obesity and overweight are important health issues. We do not have the methodology yet to accurately assess exactly how many cases of death are associated with either one of these conditions, and we may never have the perfect answer.

But we do know from a confluence of a lot of different kinds of data that both of these health problems are relevant to people and, as sad as it is, we have to come to grips with the fact that it's not healthy to be overweight.

I will say that we don't want to focus just on weight per se, because what we're really talking about here is the balance between physical activity and proper nutrition and overall health fitness. Weight is a surrogate marker of fitness. So the most accurate way of framing this would be to say because overweight is associated very often with poor fitness, that concentrating on improving fitness, and, hence, weight normalization are very important strategies for improving the quality of life and also in many cases the length of life.

The second question about the overall investment in dollars in obesity at CDC. We are investing millions of dollars in our overall programs for nutrition and physical exercise. We have new dollars going to the research agenda, new dollars going to support the trailblazer process, and new dollars to support the very specific research that was focused in the IOM report on improving the methodologies, and if you want to have a breakdown of our budget, certainly feel free to get back to us after this press conference, and we can give you the very specific numbers.

I'll take another phone question, please.

I see them queued up, but I'm not hearing them.

Then I'll just take a question here in the room until we get phone back connected.

QUESTION: Okay. Thank you. One question about methodology. If I understand it, the study that you helped out on and many others have used data that is self reported by people, and the newer study and some others have used data that where their height and weight is directly measured.

I'm just wondering given the fact that societal pressures may cause a lot of people to report their own height and weight a little bit differently than they actually are. Does it make any sense to use those figures in estimating?

DR. GERBERDING: Thank you for asking that question. I did notice on my driver's license that I might possibly have underestimated my weight a small amount.

You're right. That self reported data are usually not as reliable as objectively measured data, and that is one of the components of any study that can introduce a bias in one direction or another. The more recent CDC study used data from something called NHANES, which is the National Health and Nutrition Examination Survey, and this is a population based study that does call people in for a physical examination and accurate measurements of their weight and height.

But differences in the study can't be attributed just to those changes in methodology. And we see this process all the time in science.

People use different methods to study the frequency of West Nile virus. They use different methods to understand the distribution of heart attacks in society, and people come up with different estimations.

So I think the challenge is to take the scientific information and to make sure that we synthesize out of it the most important message that we want people to remember when they're making decisions about their own health or the health of their families. And, again, that important message here is that overweight and obesity are critically important health issues and we need to continue to focus on them as a society, but also as citizens.

I'll take a telephone question.

OPERATOR: Thank you. Gina Kolata, from the New York Times, your line is open.

QUESTION: Hi. Thanks for taking my question. I hate to keep coming back to this question of overweight, because I know you've been asked it several times, but I thought that the real--the confusion was not is there a--the question wasn't really was there a health risk to being overweight. The paper I thought was saying is there a risk of death. Are there excess deaths when you're overweight as compared to when you're normal weight or when you're obese.

And I thought what they said in the paper was if you look at excess deaths, there are fewer in the overweight category than in the normal or the obese category.

I was wondering whether that's why you're saying that--

DR. GERBERDING: [In progress]. Of why this study may have found this kind of observation, because remember when people are very ill with chronic conditions, for example, people who have end-stage of a cancer or a serious condition, an immunodeficiency, very often they're underweight. And so the reference sample in the study, which was assigned a level association with death included people who actually had chronic diseases and may have been in that category because they were ill.

So when you compare that to people who were slightly overweight, you can get a paradoxical finding. That's one of the issues that has come up in the scrutiny of the elements of that study, and there are other examples that people have focused on as explaining this finding in the study that deserve more attention and independent assessment.

So we don't want to confuse people by focusing on particular study that has its own--every study has its biases and its limitations. When, in science, one of the ways to compensate for a particular methodology or a particular finding is to look at eh body of the work, the cumulative information we have. We get information about these associations from the kinds of studies that have been recently published, but we also get this kind of information from other kinds of studies, like case control studies where we take people who have the condition and people who don't have the condition and we compare their outcomes over time. Those are the kinds of studies that have helped us have a different frame on the association between fitness and death.

And I think we're looking at the body of literature in aggregate when we make the statement that our best interpretation of the science today is that both of these health conditions are important. Both of them deserve CDC's attention and we intend to put the full weight of our scientific and public health capacity to focus on helping our nation do something about them.

I'll just take one more question from the phone, please.

OPERATOR: Thank you. Todd Zwillich from Web MD News, your line is open.

QUESTION: Dr. Gerberding. Are there--so these so-called detectives have gone into West Virginia. Are there plans to send them into any other states, any schedule to do that?

DR. GERBERDING: CDC doesn't send people into the states. We get invited, and we are just delighted that the health officials in West Virginia appropriately recognized that they had a serious problem with obesity in their state, and they really wanted to do more than just describe it. They wanted to get a team of people in there to really define the determinants of that problem and use our best epidemiologic disease detective science to profile where the problem was, how is it growing, who had it, how bad was it, and really get a much deeper understanding of it.

So we do that at the invitation of health officials and we have a large cadre of disease detectives, and we look forward to doing everything we can to help state and local governments solve this problem.

I'd like to just end again by thanking my colleagues here, especially my colleagues from DeKalb County, who so willingly came forward to just give us a little vignette of what some of the things are going in the front line.

Certainly our colleagues in the Coordinating Center for Health Promotion. Dr. Mensah, who's the head of our Chronic Disease Center and has been one of the chief scientists pulling all of these data together, as well as others at CDC who have helped not only with this press briefing but also with the whole work that is involved in identifying and responding to health threats.

Thank you for your attention.

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