Current Status and Activities to Decrease the Prevalence of Obesity Among U.S. Children and Adolescents
Tuesday, March 26, 2009
William H. Dietz, MD, PhD
Director Division of Nutrition, Physical Activity, and Obesity National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention U.S. Department of Health and Human Services
Chairman Baca and Members of the Subcommittee, thank you for the opportunity to provide this statement for the record for today′s hearing on the nation′s childhood obesity epidemic. I am Dr. Bill Dietz, Director, Division of Nutrition, Physical Activity, and Obesity, located in CDC′s National Center for Chronic Disease Prevention and Health Promotion. My statement provides you with an overview of the childhood obesity epidemic including updated surveillance data on youth overweight and obesity; the financial cost that treating overweight and obesity places on our healthcare system; and a description of integrated activities illustrating the implementation of policy approaches supported by the CDC to combat the childhood obesity epidemic.
In order to improve the health and quality of life of Americans, now and for the next generation, while keeping our healthcare budget under control, we need to invest in prevention. At every stage of life, eating a nutritious, balanced diet and staying physically active are essential for health and well–being. This is especially true for children and adolescents who are developing the habits they will likely maintain throughout their lifetime.Thus, developing effective population–level interventions that create supportive healthful environments for young people and their families is an opportunity to affect positive health outcomes throughout the lifespan.
Childhood obesity is an epidemic in the United States, one that is negatively impacting the physical and emotional health of our children, their families and society as a whole. The multiple, complex causes of childhood obesity present a compelling case for integrating multiple disciplines in a coordinated, comprehensive effort to halt and reverse the epidemic. Obesity in children is defined using the Body Mass Index (BMI), a calculation of a child′s height and weight as adjusted for gender and age based on CDC′s Growth Charts for the United States. A child is considered overweight if his or her BMI is between the 85th and 95th percentiles, and obese if his or her BMI is greater than or equal to the 95th percentile.
The prevalence of obesity among American youth increased radically between the 1980′s and the present decade. Between 1976 and 1980, approximately 5 percent of youth 2 to 19 years of age were obese.1 In 2006, the rate had increased to 16.3 percent. In fact, obesity among children aged 2 to 5 years doubled, increasing from 5 percent to 12.4 percent; among children 6 to 11 had doubled, increasing from 6.5 percent in 1980 to 17.0 percent in 2006; and tripled among adolescents aged 12 to 19, increasing from 5 percent in 1980 to 17.6 percent in 2006.2 Furthermore, 11.3 percent of children and adolescents aged 2 through 19 years were found to be severely obese, that is, their BMI was above the 97th percentile.3
There are disparities by race, ethnicity and socioeconomic status in the prevalence of obesity among youth. In 2004, 14.8 percent of children 5 and under from low–income families were obese compared to 10.4 percent of those from moderate to high income families. 4 Among males aged 12 to 19, more than 25 percent of Mexican American were obese, compared with 15.5 percent of non–Hispanic whites. Among females aged 12 to 19 years, the obesity prevalence was higher among non–Hispanic Blacks (27.7 percent) and Mexican Americans (19.9 percent) compared to non–Hispanic whites (14.5 percent).5
As noted previously, recent trends reveal that among all youth, the rate of obesity appears to have leveled; there has been no statistically significant increase or decrease for either boys or girls 2–19 years of age between survey years 1999–2000 and 2005–2006. Recent data also show a plateau of obesity rates among U.S. children and adolescents that participate in the Women, Infants and Children (WIC) Supplemental Nutrition Program.6 We cannot, however, become complacent about this plateau. Sixteen percent of our youth remain obese, and we have not achieved a reduction in obesity among this population group.
Obesity in adults is associated with serious health concerns that we are now beginning to see in children. A 2007 study reported that 70 percent of obese young people already had at least one additional risk factor for cardiovascular disease, while 39 percent had at least two additional risk factors.7 And consider Type 2 Diabetes Mellitus (T2DM), historically referred to as adult–onset′ diabetes. Type 2 Diabetes Mellitus was virtually unknown in children and adolescents 10 years ago; now children and adolescents account for almost 50 percent of new cases of T2DM in some communities.8
Childhood obesity can become a chronic condition affecting the individual and their families throughout their lifetime. Children and adolescents, who are overweight, are more likely to be overweight or obese as adults. One study found that after age 6, obese children have a greater than 50 percent chance of becoming obese adults, regardless of parental obesity status.9 In another study, obese adults who experienced childhood obesity before the age of 8 were more severely obese (had higher adult BMI) than were individuals who became obese as teenagers or adults.10 Adults who were obese as children may have earlier onset of co–morbidities (e.g., diabetes, cardiovascular disease, some cancers) and prolonged health effects from these co–morbidities and other conditions (e.g., arthritis, reproductive health complications, memory loss).11
The care and treatment of obesity and its co–morbidities over the lifespan can be costly. Economic data show that in 2001 dollars, obesity–associated annual hospital costs among youth were estimated to have more than tripled from $35 million in 1979–1981 to $127 million in 1997–1999.12 More than 25 percent of the rise in medical costs between 1987 and 2001 has been attributed to obesity.13 Between 1987 and 2002, the cost of obesity to private insurers increased tenfold, from $3.6 billion to $36.5 billion.14 In 2003, approximately half the cost of treating obesity was paid through Medicare or Medicaid.15 One reason for the higher medical costs is the prevalence of obesity–associated co–morbidities, such as diabetes and cardiovascular disease, which also require treatment and management.16 Another contributing factor may be inconsistent use of and lack of uniformity in applying billing codes to obesity–related treatments such that bill coding attributes the cost of care to a co–morbidity (e.g., diabetes) rather than to obesity as an underlying condition).
Some youth–targeted obesity interventions have been shown to have a positive return on investment. For example, Planet Health, a school–based obesity prevention program, cost $33,677 for 1200 middle school students over 2 years, or $14 per student per year. An economic evaluation of the program found that it would prevent an estimated 1.9% of the female students from becoming overweight or obese adults. As a result, for every dollar spent on the program, $1.20 would be saved in future medical costs and loss of productivity costs.17
Monitoring Physical Activity and Nutrition
Several sources of CDC–funded surveillance or monitoring data allow us to track obesity related behaviors and other risk factors among the nation′s youth.18 Behaviors and risk factors monitored by CDC tracking systems include rates of physical activity and critical indicators of nutrition (e.g., fruit and vegetable consumption, maternal breastfeeding practices). We use these data to assess the health of our youth and develop relevant interventions designed to integrate multiple settings (i.e., communities, medical care and schools) in efforts to support healthier behaviors for children and their families.
Recent tracking data indicate that for too many children and their families, proper nutrition and physical activity are not part of their daily lives. For example, the recently released Physical Activity Guidelines for Americans from the Department of Health and Human Services recommends that all young people ages 6 to 19 engage in moderate to vigorous activity that add up to 60 minutes of physical activity daily.19 Unfortunately, more than 60 percent of our young people do not meet this recommendation. On most days of the week, only 34.7 percent of young people in grades 9 through 12 report that they regularly engage in vigorous physical activity.20 Further, the 2005 Dietary Guidelines for Americans encourages all Americans to daily consume fruits and vegetables in amounts sufficient to meet their caloric needs based on age, height, weight, gender, and level of physical activity. However, between 1999 and 2007, the percentage of U.S. youth in grades 9 through 12 who reported eating fruits and vegetables five or more times per day declined from 23.9 to 21.4 percent.21 These factors may have had a direct impact on the nation′s childhood obesity rate. That students cannot meet these physical activity and nutrition recommendations illustrates the need to develop public policies that create and support environments that allow for regular and routine physical activity and access to healthful foods for our youth.
What has Contributed to the Leveling of Obesity Rates?
The recent data showing a plateau of obesity rates among U.S. children and adolescents are encouraging. The cause of this plateau has not been scientifically determined. However, CDC notes that greater public awareness resulting from press and media attention to the problem likely contributed to the present leveling of obesity rates. Yet, we strive not simply to stop the increase in obesity rates, but to reverse the epidemic. Implementing policy and environmental change initiatives at the national, state and community level that have the potential to decrease the prevalence of youth obesity may help reverse the epidemic among youth and adults.Such initiatives can include:
- seeking to eliminate so–called food deserts in urban and underserved areas where there is little or no access to healthy foods;
- expanding public transportation services and improve road conditions to allow for non–vehicle transit;
- expanding physical activity opportunities for youth; and
- improving and increasing access to healthy foods in schools and communities.
CDC Activities to Prevent and Control Obesity through Population–Level Interventions
Currently, CDC′s efforts to address the obesity epidemic are focused on policy and environmental strategies that can improve the health of all U.S. children and adults by making the places in which we live, learn, work, play, and pray, more supportive of healthy eating and physical activity.Through innovative partnerships and funded state programs, we are identifying, implementing and evaluating a variety of policy and environmental strategies in order to prioritize best and promising practices at the community, state and national level. Our efforts revolve around six target areas, prioritized because they address a significant disease burden, are supported by reasonable or logical evidence, and can prevent and control obesity at the population–level. These six strategies include:
- increasing physical activity;
- increasing fruit and vegetable consumption;
- increasing breastfeeding initiation, duration, and exclusivity;
- decreasing television viewing;
- decreasing consumption of sugar–sweetened beverages; and
- decreasing consumption of foods high in calories and low in nutritional value.
Because some barriers to nutrition and physical activity are specific to particular settings (e.g., workplaces, communities, medical care, and schools and childcare centers), CDC seeks to develop strategies, tools and resources that can assist practitioners in providing integrated health messages and coordinated interventions to prevent and control childhood obesity. CDC′s major program areas to address childhood obesity include grants for state–based Nutrition and Physical Activity, Coordinated School Health, as well as for Healthy Communities.
Nutrition, Physical Activity and Obesity State Plans: CDC provides funding to twenty–three states to coordinate statewide efforts to address obesity through policy and environmental changes focused on CDC′s six strategies mentioned above. The program also addresses health disparities and requires a comprehensive state plan. A good example of one of these initiatives is from Washington State.A series of initiatives, now known as Healthy Communities Moses Lake, have encouraged good nutrition and physical activity behaviors through environmental and policy change. Accomplishments include widening of sidewalks, creating an interconnected system of paths for pedestrians and bicyclists, and fostering an environment conducive to outdoor physical activity. The projectalso developed a community garden which provides residents and participants with greater access to fresh, nutritious produce as well as opportunities to engage in physical activity through gardening. In addition, to encourage good nutrition from birth, Healthy Communities informs residents about proper breastfeeding practices and creates supportive environments for nursing mothers throughout the community.
Coordinated School Health: CDC also funds twenty–two state–based education and health agencies and one tribal government to implement coordinated school health programs. These programs bring together school administrators, teachers, other staff, students, families, and community members to assess health needs; set priorities; and plan, implement, and evaluate school health activities, including those focused on physical activity and healthy eating among school–aged youth. This program fosters collaboration between state and local authorities, as well as between state departments of health and education. In Mississippi, for example, the Department of Education worked with CDC, the Bower Foundation, the Alliance for a Healthier Generation, and other partners to set new nutritional standards for school snacks and meal programs, and impose a ban on sugar–sweetened beverages. Forty–one school districts purchased 104 combination oven steamers, replacing the traditional deep–fat fryers and thereby substantially decreasing the amount of high–calorie, fatty foods eaten by almost 65,000 of the state′s school children. Additionally, Wisconsin′s Movin′ and Munchin′ Schools campaign to promote physical activity and healthy eating as lifetime habits resulted in 101,641 students, 39,143 parents, and 9,265 staff reporting increases in physical activity and fruit and vegetable consumption.
Healthy Communities: Since 2003, Healthy Communities (formerly referred to as Steps to a HealthierUS) has supported local communities in implementing evidence–based interventions in community–based settings including schools, workplaces, community organizations, health care settings, and municipal planning, and in achieving local changes necessary to prevent obesity and related risk factors. Special focus has been directed toward populations with disproportionate burden of disease. Communities receive funds to spark local–level action, change community conditions to reduce risk factors for obesity, establish and sustain state–of–the–art programs, test new models of intervention, create models for replication, and help train and mentor additional communities.
Examples of Integrated Approaches to Address Childhood Obesity
We know that any effort to combat childhood obesity will take a multi–pronged approach aimed at improving population–level indicators of health and include not just CDC and the federal government, but states, localities and our national and local partner organizations. Coordinating our efforts across sectors, including education, agriculture, and transportation, and leveraging our resources to affect policy and environmental changes is necessary if we want to see obesity trends decrease. One such partnership is between CDC, the United States Department of Agriculture, and the United States Department of Education in a joint project called Making It Happen! School Nutrition Success Stories.This reporttells the stories of 32 schools and school districts from across the United States (grades K–12) that have implemented innovative strategies to improve the nutritional quality of foods and beverages sold outside of federal meal programs. Another partner in our efforts is the Alliance for a Healthier Generation, ajoint partnership between the Clinton Foundation and the American Heart Association. The Alliance has worked with industry and school districts to develop guidelines on the provision of competitive foods and beverages in schools, and most recently began a new campaign working with national medical associations, insurers and employers to provide comprehensive health benefits to obese children and their families.22
In addition to our partners, many cities and localities have started their own childhood obesity initiatives including New York City′s Department of Health and Mental Hygiene. The city developed and implemented a regulation that specifically improves the nutritional and physical activity habits of children in the city childcare programs. The regulation prohibits the availability of sugar–sweetened beverages; permits only 6 oz. of 100% juice for children 8 months or older; permits children 12 months to under 2 years to have whole milk and then limits milk to 1% or less for children 2 years of age or older; requires water to be available and accessible to children throughout the day; requires children 12 months and older to participate in 60 minutes of physical activity per day and for children 3 years or older to participate in 30 to 60 minutes of structured physical activity per day; and restricts television viewing for children under 2 years of age, and limits television viewing to no more than 60 minutes per day of educational programming or programs that actively engage children in movement to children 2 years of age or older.
Another example can be found in Florida, where the Pinellas County Childcare Licensing Board requires a minimum of 30 minutes of physical activity, 5 days per week, for all children as a condition of childcare licensure. And in 2008, the state of Florida passed a law requiring each school district to provide 150 minutes per week of physical education for students in grades K to 5, and for students in the 6th grade when the school has one or more elementary grades. Beginning in 2009, school districts will have to expand the physical education requirement so students in grades 6 to 8 receive one physical education class per day each semester. The effect of these policies is a coordinated effort across jurisdictions and sectors to increase daily physical activity for all children from pre–school through the 6th grade. As a result, many children in Pinellas County now meet the national recommendation of 60 minutes of physical activity daily.
And in California, to create healthy environments where people can thrive, the California Convergence has convened leaders from 26 communities to collaboratively develop a common policy agenda, build a statewide communication infrastructure, influence funding strategies, and generate public revenue to support their work. As a result, officials have identified the need to improve nutrition standards in those places where children spend most of their time, (including schools, after school and childcare environments), and a broad range of strategies that focus on local, state and national level health impact.
Given the challenges ahead, CDC will continue to develop and evaluate policy and environmental strategies to determine effective population–level interventions that will provide a positive impact on the health of our nation′s youth. We applaud recent changes in federal policy to support healthier eating; updating WIC program requirements to be more in line with the Dietary Guidelines for Americans, and the inclusion in the 2008 Farm Bill (Food, Conservation and Energy Act of 2008, Public Law 110–246) of the Healthy Urban Food Enterprise Development Center and the school–based Fresh Fruit and Vegetables Program provisions.These provisions, like others implemented through the 2008 Farm Bill, will help incentivize the consumption of fruits and vegetables. Agricultural policies like these support American families in making healthy food choices, thereby ensuring healthier diets among some of our most at–risk children.
Further, we cannot forget the impact of physical activity and proper nutrition on student academic achievement and classroom participation. A 2008 elementary school study found that physical activity may be associated with improved academic performance for girls and had no negative effect on academic achievement for elementary school children.23 And, among children living in the urban areas of Baltimore, Maryland and Philadelphia, Pennsylvania, those who participated in the School Breakfast Program increased their nutrient intake and were more likely to improve their academic and psychosocial functioning than those who did not participate in the program.24
Lastly, we are compelled to acknowledge the causal relationship between food insecurity and obesity. 25 Though it may appear paradoxical, families faced with food insecurity are more likely to augment their diet with high energy density, low nutritional value foods and, therefore, have high rates of obesity. Obesity is not a symptom of eating well but an indicator of poor diet.Persons living in low income communities often do not have access to fresh produce making foods of low nutritional value an affordable option to satiate their hunger.With increasing unemployment and concurrent demand on public and privately funded food service facilities, it is imperative that we pursue policies that ensure proper nutrition among persons experiencing the greatest obesity– related health disparities.
In closing, I would like to thank the Committee for its leadership and commitment to the health of our nation′s youth.Making balanced nutrition and regular activity a routine part of life will take a committed, coordinated effort that will need to endure for decades to come.
Positively impacting the health of our youth offers promising prevention opportunities. We know that the young can benefit from better nutrition, and increased physical activity, as well as from other preventive efforts. While medical treatment for disease management is essential, our nation needs a better balance between treating diseases and preventing them.
There is much we can do to prevent disease and conditions related to obesity that contribute so heavily to disability and death, the need for long–term care, and escalating health care costs.Our youth have an urgent need for more and better prevention policies and environmental change initiatives.I look forward to working with my colleagues in the United States Department of Agriculture to further discuss agriculture policies and their impact on the public′s health.
- Obesity Prevalence, Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity and Obesity, (children 2–5 years, 5%, children 6–11 years, 6.5%, children 12–19 years, 5%). https://www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm, last visited March 20, 2009.
- Ogden CL, Carroll MD, Flegal KM. High Body Mass Index for Age Among US Children and Adolescents, 2003–2006. JAMA. 2008;299(20):2401–2405.
- CL Ogden, MD Carroll, KM Flegal. High Body Mass Index for Age Among US Children and Adolescents, 2003 2006. JAMA. 2008;299(20):2401–2405.
- Polhamus B, Thompson D, Dalenius K, Borland E, Smith B, Grummer–Strawn L. Pediatric Nutrition Surveillance 2004 Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2006
- Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among U.S. children and adolescents, 19992000. JAMA 2002;288:17281732.
- Polhamus B, Dalenius K, Borland E, Mackintosh H, Smith B, Grummer–Strawn L. Pediatric Nutrition Surveillance 2007 Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.
- Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The Bogalusa Heart Study. J Pediatr. 2007 Jan; 150:12–17.e2.
- American Diabetes Association (ADA). 2000. Type 2 Diabetes in Children and Adolescents. Pediatrics 105:67180
- Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting Obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337(13): 869–73.
- Relationship of Childhood Obesity to Coronary Heart Disease Risk Factors in Adulthood: The Bogaluse Heart Study. Pediatrics, 2001;108(3): 712–718.
- Ferraro, K.S., R.J. Thorpe Jr., and J.A. Wilkinson. 2003. The Life Course of Severe Obesity: Does Childhood Overweight Matter? Journals of Gerontology, Series B, Psychological Sciences and Social Sciences 58(2):S11019
- Wang G and Dietz WH. Economic Burden of Obesity in Youths Aged 6 to 17 years: 1979–1999. Pediatrics. 2002;109;e81
- Thorpe, K.E., C.S. Florence, D.H. Howard, and P. Joski. 2004. The Impact of Obesity on the Rise in Medical Spending. Health Affairs,JulyDecember (suppl. web excl.):W4–48086.
- Thorpe, K.E., C.S. Florence, D.H. Howard, and P. Joski. 2005. The Rising Prevalence of Treated Disease: Effects on Private Health Insurance Spending. Health Affairs, JanuaryJune (suppl. web excl.):W5–31725
- Finkelstein, E., et al. State–Level Estimates of Annual Medical Expenditures Attributable to Obesity. Obesity Research, January 2004: V12. No 1: 18–24.
- Thorpe, K.E. 2006. Factors Accounting for the Rise in Health–Care Spending in the United States: The Role of Rising Disease Prevalence and Treatment Intensity. Journal of the Royal Institute of Public Health 120:10027
- Wang, L.Y., Yang, Q., Lowry, R, Wechsler, H. Economic analysis of a school–based obesity prevention program. Obesity Research 2003; 11:13131324.
- Pediatric and Pregnancy Nutrition Surveillance System (PedNSS);Youth Risk Behavior Surveillance System (YRBSS); National Health and Nutrition Examination Survey (NHANES)
- 2008 Physical Activity Guidelines for Americans, at http://www.health.gov/PAGuidelines/External , last visited March 20, 2009
- CDC. Youth Risk Behavior SurveillanceUnited States, 2007Cdc-pdf [pdf 1M] Morbidity & Mortality Weekly Report 2008;57(No.SS–4).
- CDC. Youth Risk Behavior SurveillanceUnited States, 2007. Morbidity & Mortality Weekly Report 2008;57(SS–05):1131
- Carlson SA, Fulton JE, Lee SM, Maynard LM, Brown DR, Kohl HW, Dietz WH. Physical Education and Academic Achievement in Elementary Schools: Data From the Early Childhood Longitudinal Study. Am J Public Health, 2008;98(4):721–727
- Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE. The Relationship of school breakfast to psychosocial and academic functioning: Cross–sectional and longitudinal observations in an inner–city school sample. Archives of Pediatrics and Adolescent Medicine 1998; 152(9); 899–907.
- Tufts University School of Medicine, Case Report, Does Hunger Cause Obesity. Pediatrics 1995;95:766–7; Freedman DS, Ogden CL, Flegal KM, Kettel–Khan L, Serdula MK, Dietz WH. Childhood Overweight and Family Income. Medscape General Medicine, 2007;9(2):26