U.S. Department of
Health and Human Services

National Institutes of Health

WIN Notes

Spring 2008

In This Issue:

Cover Story

NIDDK Director Addresses World Diabetes Day

November 14, 2007 marked the first United Nations-observed World Diabetes Day. Griffin P. Rodgers, M.D., Director of NIDDK, released a special statement for this global date of awareness-raising.

Dr. Rodgers reflected on the progress that researchers and clinicians have made in the past 10 years with regard to the treatment and understanding of type 1 and type 2 diabetes. For instance, we now know that an individual’s risk of type 1 diabetes may be predicted with blood samples, and that type 2 diabetes may be prevented or delayed in high-risk populations.

The topic of this year’s World Diabetes Day was diabetes in children and adolescents. In his remarks, Dr. Rodgers highlighted a number of NIH-funded studies of diabetes in youth.

Studies of type 1 diabetes aim to prevent the disease and its complications, explore its genetic underpinnings, identify environmental factors influencing its development, and improve treatment technologies. These studies are national and international in scope, and involve infants, children, adolescents, and their families.

Type 2 diabetes research funded by NIH also focuses on genetics, prevention, and treatment. For instance, one national study is evaluating a school-based prevention program providing a healthier diet and physical activity opportunities to middle school students. Another study is assessing the effectiveness of the drug metformin when it is combined with diet and physical activity.

NIH dedicated approximately $1 billion to fund diabetes research in fiscal year 2007. Dr. Rodgers stressed that NIH is committed to furthering diabetes research and practical applications in the years to come.

The complete statement may be read at www.nih.gov/news/pr/nov2007/niddk-14.htm.

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Research Notes

Fitness Strongly Protects Against Mortality Among Older Adults

The health risks associated with overweight and obesity are widely known. We also know that being physically fit is protective against a number of health conditions. One might wonder, “Well, which is more important: having a normal level of body fat, or being fit?”

A recent study by researchers from the Universities of South Carolina, Buffalo, and North Texas examined this very question in a sample of 2,603 adults over age 60. Researchers chose an older population for the study because few previous studies examine both physical activity and body fat in relation to mortality in this group. Furthermore, earlier research showed that increased body weight is protective against mortality among the elderly. Researchers were curious to explore this association further.

The researchers performed baseline health examinations from 1979 to 2001, including an exercise test that determined aerobic fitness and tests to determine adiposity (body fatness). Subjects were primarily White, well-educated, middle- to upper-class men who were fit enough to complete the fitness test at the start of the study. By 2003, researchers completed follow-up surveillance on the subjects and determined the number of deaths by all causes. The average follow-up time was 12 years.

There were 450 deaths during the follow-up period. Researchers analyzed the data to determine if fitness and different measures of adiposity affected the risk of dying. Results supported the line of thinking that, among older adults, fitness may be more important than fatness in all-cause mortality.

Fitness exhibited a clear relationship with mortality. The fitter a person was, the lower his or her mortality risk. Even after adjusting for percentage of fat and placement of fat (that is, whether fat was located in the belly), fitness was still an important predictor of mortality risk.

The results for adiposity were not as straightforward. Total percentages of body fat and waist circumference (which estimates belly fat) were not associated with mortality risk after accounting for the effects of fitness. Only body mass index, a measure of weight in relation to height, was associated with mortality: individuals above and below healthy body weights had an increased risk of death.

Researchers acknowledged that the subjects of this study were relatively similar to one another, a fact that limits the extent to which results can be extended to other groups. The researchers noted, however, that this helped avoid the potential effect that education and income might have on the results. Another limitation of the study was that diet and medication use were not examined. These factors might have played a role in mortality.

The take-home message of these findings is that regardless of body size, increasing one’s fitness lowers the risk of death. Furthermore, other studies have shown us that it is never too late to become more physically active, and even the very elderly may benefit from added exercise.

Article Information
Sui X, LaMonte M, Laditka N, et al. Cardiorespiratory Fitness and Adiposity as Mortality Predictors in Older Adults. Journal of the American Medical Association. 2007;298(21):2507–2516.

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Study Examines the Association Between Weight and Cause of Death

The increase in overweight and obesity in the United States has raised concerns about subsequent increases in chronic illnesses such as heart disease. Rising rates of overweight and obesity also raise concerns about the association between body weight and excess mortality. As noted in the fitness study summarized above, weight is associated with mortality. In fact, individuals with higher- and lower-than-normal body weights have an increased risk of death. But does this increased risk of death vary according to the cause of death?

Researchers from the Centers for Disease Control and Prevention and the National Cancer Institute examined the association between cause of death and weight among U.S. adults age 25 and older. Researchers used results from four consecutive National Health and Nutrition Examination Surveys (NHANES) to estimate excess mortality associated with different body mass indices (BMIs) for underweight, normal weight, overweight, and obesity. BMI is a measure of weight in relation to height that is commonly used by health care professionals to determine the effect of body weight on the risk for some diseases. The researchers analyzed data from NHANES I, 1971–1975; II, 1976–1980; and III, 1988–1994. These data were combined with BMI ratios and other covariates from NHANES 1999–2002 and with underlying cause of death data for about 2.3 million adults in 2003.

The researchers grouped deaths into three categories: 1) cardiovascular disease (CVD), 2) cancer, and 3) all other causes (noncancer, non-CVD causes). When using all follow-up from all surveys, underweight was associated with significantly increased mortality from noncancer, non-CVD causes (23,455 excess deaths) but not associated with increased cancer or CVD mortality. Overweight was associated with a significantly decreased mortality from noncancer, non-CVD causes (69,299 fewer deaths than expected) but was not associated with increased or decreased cancer or CVD deaths. Researchers found that obesity was associated with a significantly increased mortality from CVD (112,159 excess deaths) but not associated with increased all-cancer mortality or with noncancer, non-CVD mortality.

Overweight and obesity together were associated with increased mortality from diabetes and kidney disease (61,248 excess deaths) and decreased mortality from other noncancer, non-CVD causes (105,572 fewer deaths than expected). Obesity, not overweight, was associated with an increased mortality from cancers considered obesity-related, such as colon, breast, esophageal, uterine, ovarian, kidney, and pancreatic (13,839 excess deaths). However, obesity was not associated with mortality from other cancers. Researchers also noted that comparisons of data across surveys suggested a decrease in the association of obesity with CVD deaths over time.

Study results were similar to an earlier investigation by this research group, which estimated BMI-related excess mortality in the United States in 2000 using data from national surveys. (That study was published in the April 20, 2005 issue of the Journal of the American Medical Association.) However, in the original analysis, cause of death was not specifically examined. This subsequent study clarifies the association between BMI and mortality, showing that it varies considerably by cause of death.

Article Information
Flegal K, Graubard B, Williamson D, et al. Cause-Specific Excess Deaths Associated With Underweight, Overweight, and Obesity. Journal of the American Medical Association. 2007;298(17):2028–2037.

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Pediatric Overweight May Increase Future Heart Disease Risk

A paper published in The New England Journal of Medicine cast light on the potential dangers of overweight during adolescence. The study was conducted by a group from the University of California, San Diego; San Francisco General Hospital; and the College of Physicians and Surgeons at Columbia University. Using current statistics, historical trends, and a computer model that projects future disease risks, the authors predicted that obesity and coronary heart disease (CHD) rates will increase significantly when today’s generation of adolescents become young and middle-age adults.

According to Government estimates, 16.7 percent of adolescent boys and 15.4 percent of adolescent girls were overweight in 2000, defined as above the 95th percentile for weight. By 2020, this generation of overweight teens is expected to increase the proportion of obesity among 35-year-old men and women. These higher obesity rates, in turn, are expected to increase the rates of CHD events and deaths. Rates of obesity and CHD may rise even more by 2035.

The aim of the study was not to paint a bleak picture. Researchers also examined the potential effects of treating obesity-related high cholesterol and high blood pressure. Successful treatment would substantially decrease death and illness from CHD. However, treating high cholesterol and high blood pressure would not eliminate the risk of diabetes from obesity, so the number of events from CHD and other diseases would still be elevated.

The authors stressed that projections are not definite forecasts. Trends and factors not considered by the researchers might alter real-life obesity and CHD rates. However, it is worth noting that increases were seen even when the researchers used conservative estimates. Further, adolescent overweight increases the likelihood of health problems before adulthood.

Teens tend to think in the “here and now” and are not generally motivated by future health risks, but these long-term consequences may add another source of inspiration for adolescents who are struggling to manage their weight.

Article Information
Bibbins-Domingo K, Coxson P, Pletcher M, et al. Adolescent Overweight and Future Adult Coronary Heart Disease. The New England Journal of Medicine. 2007;357(23):2371–2379.

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Dietary and Obesity Reports

Weight-maintenance Programs for Children Effective in the Short-term

Weight-loss maintenance is notoriously difficult. A recent study shows that this is true for children as well as adults, but that enrollment in targeted programs can help in the short-term.

Researchers evaluated the results of two 16-week, family-based pediatric weight-maintenance programs that followed a 5-month weight-loss program. One intervention used a behavioral skills maintenance (BSM) approach, which builds on weight-loss skills and teaches new skills unique to long-term weight control. The other intervention used social facilitation maintenance (SFM), which emphasizes peer circles and friend support. The results were compared with a control group consisting of children who participated in the weight-loss program but did not receive a weight-maintenance intervention.

Program participants were 7- to 12-year-old children who were 20- to 100-percent overweight and had at least one parent who was overweight. At least one parent of each child also participated in the programs.

During the weight-loss program (in which all three groups participated), all but 19 of 150 kids lost weight. Success in losing weight did not relate to future success maintaining weight. The short-term results of the weight-maintenance interventions were promising. Children in both programs maintained their body mass index better than the control group from randomization to post-weight maintenance. After 2 years, children in the SFM group, who at baseline had low social problems, fared better than children in the control group. The BSM group did not significantly differ from the control group. These results mirror adult weight maintenance studies, in which the benefits fade over time.

Researchers also found that the children in the BSM and SFM programs had higher confidence for eating a low-fat diet and felt they had greater ability than their counterparts in the control group to overcome physical activity barriers. The SFM children were also better at coping with teasing, receiving encouragement from their peers to eat healthy, and enlisting friends to support their new physical activity habits over the short-term.

The authors stressed the need for effective, long-term weight control among pediatric populations. Childhood overweight has steadily grown in the United States, potentially causing negative physical and psychosocial outcomes. Treatment programs involving family and peer circles may provide help to some of these children.

Article Information
Wilfley D, Stein R, Saelens B, et al. Efficacy of Maintenance Treatment Approaches for Childhood Overweight: A Randomized Controlled Trial. Journal of the American Medical Association. 2007;298(14):1661–1673.

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Risk of Disability Increases for Obese Individuals

Researchers have long known that obesity increases a person’s risk for developing chronic illnesses such as cardiovascular disease and some cancers. Recent advances in the medical treatment of such illnesses have caused a decline in obesity-related health complications, suggesting that people with obesity are becoming healthier. However, a study by a pair of researchers from the Robert Wood Johnson Foundation and the University of Pennsylvania shows that despite medical advances, people who are obese are at increased risk of disability.

Data from the National Health and Nutrition Examination Survey (NHANES) III (1988–1994) and NHANES 1999–2004 were used to examine change in disability by body mass index (BMI). NHANES collects disability information in two areas: functional disability (referring to restrictions in basic movement ability) and limitations in activities of daily living (ADLs), which affect an individual’s ability to live independently. The recent study examined the influence of weight on functional and ADL limitations and how this relationship has changed between NHANES III and NHANES 1999–2004. Researchers focused on U.S. adults age 60 and older.

Researchers found that the likelihood of functional disability increased by 43 percent for obese individuals. In contrast, prevalence of functional disability did not change for nonobese individuals. Furthermore, while prevalence of ADL disability for nonobese individuals actually went down between NHANES III and NHANES 1999–2004, the prevalence did not change for obese individuals.

While recent improvements in the treatment of some chronic illnesses have allowed for people who are obese to lower their risk of developing such conditions, it is clear that such improvements have had no effect on reducing the incidence of disability among the obese population. In fact, the risk for developing problems with basic movement is increasing for obese individuals. Continued support for individuals with obesity in the form of weight-control programs may be necessary to help improve their quality of life.

Article Information
Alley D, Chang V. The Changing Relationship of Obesity and Disability, 1988–2004. Journal of the American Medical Association. 2007;298(17): 2020–2027.

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Race and Ethnicity Influence Household Grocery Purchases

What influences your supermarket purchases? According to new research investigating food and beverage selection at the grocery store, the race and ethnicity of people in your household may play a role.

A group of researchers from Baylor College of Medicine interviewed grocery shoppers with varying educational, racial, and ethnic backgrounds who had at least one child or teenager at home. In addition to conducting interviews, the researchers examined grocery receipts to determine the types of foods purchased over a 6-week period.

Subjects were recruited at 22 grocery stores throughout Houston in order to obtain a diverse study population. One hundred sixty-seven shoppers completed the first interview, 130 of those completed the second interview 6 weeks later, and 115 submitted their grocery receipts weekly for 6 weeks.

The subjects were primarily female, and about half of all subjects were 40 years old or younger and had a high school education or less. The majority of subjects were Black (41 percent) or Hispanic (39 percent). White subjects spent more than Blacks and Hispanics over the 6-week study period; the average for all groups was $411. The greatest percentage of grocery dollars (for all subjects) was spent on protein, followed by beverages, grains, vegetables, dairy, mixed dishes, and fruit.

Race and ethnicity significantly influenced the purchase of certain food groups. Hispanics bought more fruits and vegetables than Blacks, Whites bought more alcohol than Blacks and more mixed dishes than Hispanics, and Blacks purchased more protein than Whites. The number of children in the household did not alter the results. Educational status appeared to influence juice and dairy purchases, but the number of subjects in each racial or ethnic group with at least some college education was quite small, possibly affecting the results.

Among the study’s limitations were its neglect of foods eaten outside the home, an inability to detect lean versus high-fat protein items, and an inability to adjust for purchases such as buying large amounts of foods when they go on sale.

Nonetheless, this study should serve as a launching point for further investigations, according to the researchers. The results could also help direct educational programs. For instance, it might be useful to help Blacks choose healthful, low-cost sources of protein, since this group spent a significant portion of food dollars on protein in this study.

Article Information
Cullen K, Baranowski T, Watson K, et al. Food Category Purchases Vary by Household Education and Race/Ethnicity: Results from Grocery Receipts. Journal of the American Dietetic Association. 2007;107(10):1747–1752.

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DHHS News

Study Evaluates Nutrition Offerings in U.S. Schools

Schools are recognized as important venues to promote healthy eating to children and adolescents for a number of reasons. Many dietary preferences and habits are established during childhood. Kids spend hours a day at school, and they may consume a large percentage of daily calories there. In fact, more than half of school-age children in the United States received school breakfast or school lunch in 2004. In addition, schools are a place of learning—not only in the classroom setting, but through the implicit messages students receive from school foods.

The last few years have brought renewed interest in improving school nutrition, spurred in part by the rise of childhood overweight and increased awareness about healthy eating. The 2006 School Health Policies and Programs Study, a nationwide survey conducted by the Centers for Disease Control and Prevention (CDC), evaluated nutrition requirements, restrictions on foods and beverages sold, and healthful offerings at the State-, district-, and school-levels. School nutrition personnel from elementary, middle, and high schools in every State and the District of Columbia were interviewed.

Study results revealed many areas in need of improvement. Few States required schools to limit the sale of deep-fried foods or prohibit the sale of foods with little to no nutritional value. Few States sold healthful beverages. Even when healthful foods and beverages were sold, they were often accompanied by options high in fat, sodium, and added sugar.

Few States and districts prohibited brand-name fast foods from being offered in school meals or as à la carte items. Some States and districts restricted the times of day that junk food could be sold, or restricted student access to vending machines at certain times. However, children have access to vending machine foods and beverages at some point during the day at 86 percent of high schools, 62 percent of middle schools, and 21 percent of elementary schools. Only 2 percent of schools and 24 percent of districts forbid on-campus advertising for candy, fast food restaurants, or soft drinks.

The study authors offered a number of suggestions to improve school nutrition. For instance, food should be prepared in ways that reduce the total fat, saturated fat, sodium, and added sugar content of meals. Children and teens should be encouraged and given opportunities to eat more fruits, vegetables, whole grains, and fat-free or low-fat dairy products at school. Professional certification requirements for school food service managers should be established, and policies to decrease access to unhealthy foods and increase the availability and appeal of nutritious foods should be developed and implemented.

Several tools and guidelines are available to help schools implement recommended school nutrition strategies. Among these are CDC’s School Health Index: A Self-Assessment and Planning Guide and the National Association of State Boards of Education’s Fit, Healthy, and Ready to Learn: A School Health Policy Guide.

Article Information
O’Toole T, Anderson S, Millar C, et al. Nutrition Services and Foods and Beverages Available at School: Results from the School Health Policies and Programs Study 2006. Journal of School Health. 2007;77(8):500–521.

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NIH News

New Spanish-language Websites Available From NIDDK

NIDDK has developed three new web portals for Spanish-speaking users. The portals link to publications, resources, and interactive tools related to digestive diseases, diabetes, and kidney and urologic diseases.

The diabetes information portal is available at www.diabetes-espanol.niddk.nih.gov, the digestive diseases portal is available at www.digestive-espanol.niddk.nih.gov, and the kidney and urologic diseases portal is available at www.kidney-espanol.niddk.nih.gov.

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**NDEP Launches Tips for Teens with Diabetes Series**

The National Diabetes Education Program (NDEP) recently released the Tips for Teens with Diabetes series. These print and online materials provide ways for teens to deal with the ins and outs of diabetes. Fact sheets outline the risk factors for diabetes and ways to manage the disease and the emotions it stirs. The materials also offer tips on physical activity, nutrition, and weight management. Each fact sheet provides information about where teens can go to learn more. After reviewing the materials, teens can test their knowledge by taking an interactive online quiz.

The Tips for Teens with Diabetes series is available at http://ndep.nih.gov/diabetes/youth/youthtips/youthtips_dealing.htm.

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Cyber Notes

MyPyramid.gov Offers New Resource for Pregnant and Breastfeeding Women

MyPyramid.gov, the educational tool designed to help consumers make healthier food and physical activity choices from the U.S. Department of Agriculture, has a new section: MyPyramid for Pregnancy and Breastfeeding. The new resource recognizes the changing nutritional needs of pregnant and breastfeeding women and offers advice for moms to stay healthy during this time. Women can create a personalized “MyPyramid Plan for Moms,” detailing the types and amounts of food necessary to keep mom and baby healthy.

The new feature for pregnant and breastfeeding women can be found at www.mypyramid.gov/mypyramidmoms/index.html.

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Shrek Encourages Kids to Be Physically Active in New Video

The HealthierUS initiative is a national effort to prevent and reduce the costs of disease, improve people’s lives, and promote community health and wellness. The initiative’s website, www.healthierus.gov, offers information on physical activity, nutrition, and preventive health screenings, with a special focus on kids. Parents and kids can look at the many fact sheets, tip sheets, and videos to get the information they need to make healthy choices and live healthier lifestyles.

Shrek and his friends star in a new video to encourage kids to be physically active called “Be a Player Get Up and Play an Hour a Day.” The gang encourages kids to drop the video games, turn off the television, and get up and play for an hour each day. Simply dancing or playing on the playground with friends can help kids be more active.

To view the video and learn more about HealthierUS, go to www.healthierus.gov/video.html.

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Program Notes

WIN Reaches Out to the Media

WIN teamed up with the Washington Metropolitan Transit Authority to help the DC metropolitan community stay healthier through the winter holidays. WIN displayed healthy holiday messages using dioramas located at Metro stations throughout the Metrorail system. The messages were on display at the Ballston, Cheverly, Prince George’s Plaza, Waterfront, and Minnesota Avenue stations from December 1–31, 2007.

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WIN in the Community

WIN Participates in Local Events

In April 2007, WIN participated in the Obesity Awareness Walk-A-Thon at Coppin State University. In November 2007, WIN participated in the BET Foundation Women’s Health Symposium, also held at Coppin State University. At both events, WIN provided Sisters Together publications, magnets, water bottles, and other items in addition to WIN publications to the very appreciative attendees.

The Sisters Together program reached out to 185 African-American churches in the Washington, DC, area, encouraging Black women to maintain a healthy weight by becoming more physically active and eating healthier foods. In addition to receiving important information, the women were the first to receive the new Sisters Together lunch bags and water bottles.

Sisters Together is partnering with the Tennessee Center for Diabetes Prevention and Health Improvement and the Urban League of Greater Chattanooga to help expand their antiobesity pilot program to Black women and children. The Urban League also plans to form a statewide advisory board for the Sisters Together program. The Trust for America’s Health ranked Tennessee’s population fourth among U.S. States for the most overweight youths age 10 to 17. Tennessee was ranked fifth-highest with regard to adult obesity.

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WIN Travels the Country

WIN will be exhibiting at the following professional conferences in 2008:

CDC Division of Diabetes Translation Conference
May 5–8, 2008
Orlando, FL

American Academy of Physician Assistants Annual PA Conference
May 24–29, 2008
San Antonio, TX

National Association of School Nurses Annual Conference
June 28–July 1, 2008
Albuquerque, NM

National Urban League Annual Conference
July 30–August 2, 2008
Orlando, FL

National Black Nurses Association Annual Meeting
August 4–8, 2008
Las Vegas, NV

American Association of Diabetes Educators Annual Meeting
August 6–9, 2008
Washington, DC

The Obesity Society’s 2008 Annual Scientific Meeting
October 3–7, 2008
Phoenix, AZ

Maryland Association for Health, Physical Education, Recreation and Dance Annual Convention
October 17, 2008
Towson, MD

American Dietetic Association Food & Nutrition Conference & Expo
October 25–28, 2008
Chicago, IL

For Sisters Only Expo
November 2008
Washington, DC

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Resource Notes

Materials From WIN

WIN released a new Spanish-language publication specifically for Spanish-speaking teenagers. The publication ¡Hazte cargo de tu salud! provides teens with information regarding nutrition and physical activity, as well as tips on living a healthier lifestyle at home and at school.

Updated WIN Publications

WIN has updated and reprinted several fact sheets and brochures. The publications listed below have been revised to include the latest scientific research.

Obesity Glossary
Better Health and You: Tips for Adults
Fit and Fabulous as You Mature
Statistics Related to Overweight and Obesity
Just Enough for You: About Food Portions
Helping Your Overweight Child
Prescription Medications for the Treatment of Obesity
Talking With Patients About Weight Loss
Sisters Together Program Guide

To obtain a free copy of these or other publications, contact WIN at 1–877–946–4627 or win@info.niddk.nih.gov. You can also download PDF copies at www.win.niddk.nih.gov.

The WIN Reference Collection

The WIN Reference Collection, a database of articles and educational resources provided by WIN, has been reconfigured. Formerly known as the Health Information Database, the WIN Reference Collection features a searchable database of science-based information on weight-control, physical activity, and nutrition for the general public, health care professionals, Congress, and the media.

The WIN Reference Collection can be found online at http://win.niddk.nih.gov/resources/hid.

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Materials From Other Organizations

Loving Your Family, Feeding Their Future: Nutrition Education Through the Food Stamp Program

This new initiative from the U.S. Department of Agriculture’s (USDA) Food and Nutrition Service was designed to help low-income families make healthy food choices and increase their physical activity. Loving Your Family, Feeding Their Future is one of the first comprehensive nutrition programs based on the 2005 Dietary Guidelines for Americans. It was designed to be sensitive to the language, culture, and literacy issues faced by Food Stamp Program participants.

For more information about the Loving Your Family, Feeding Their Future initiative, please visit www.fns.usda.gov/cga/PressReleases/2007/FNS-0001.htm.

Vegetarian Nutrition Resource List

The USDA’s Food and Nutrition Information Center has published a comprehensive guide to living as a vegetarian. The Vegetarian Nutrition Resource List directs readers to articles, pamphlets, books, and websites covering many aspects of vegetarian nutrition, including resources for children and pregnant and breastfeeding women.

The Vegetarian Nutrition Resource List can be found at http://www.nal.usda.gov/fnic/pubs/bibs/gen/vegetarian07.pdf.

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Editor's Notes

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Weight-control Information Network
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