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Statement by
William H. Dietz, M.D., Ph.D.
Director, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention, U.S. Department of Health and Human Services
on
CDC's Role in Combating the Obesity Epidemic
before the
Senate Committee on Health, Education, Labor and Pensions

May 21, 2002

Good morning. I am Dr. William Dietz, Director of the Division of Nutrition and Physical Activity at Centers for Disease Control and Prevention. I am pleased to be here today to participate in this important discussion of the obesity epidemic.

Burden of Obesity

The burden placed on our society by obesity and related chronic diseases is enormous. In the last 20 years, obesity rates have increased by more than 60 percent in adults. Since 1980, rates have doubled in children and tripled in adolescents. More than 25 percent of the adult population in the United States is obese, or approximately 50 million adults. Almost 15 percent of our children and adolescents are overweight, or approximately eight million youth. Rates of obesity have increased more rapidly among African Americans and Mexican Americans than among Caucasians. Obesity in the United States is truly epidemic.

We have already begun to see the impact of the obesity epidemic on other diseases. For example, type 2 diabetes, a major consequence of obesity, also has increased rapidly over the last 10 years. Although type 2 diabetes was virtually unknown in children and adolescents 10 years ago, it now accounts for almost 50 percent of new cases of diabetes in some communities. Obesity is also a major contributor to heart disease, arthritis, and some types of cancer. Recent estimates suggest that obesity accounts for 300,000 deaths annually, second only to tobacco related deaths.

The contribution of childhood onset obesity to adult disease is even more worrisome. Although onset of obesity in childhood only accounts for 25 percent of adult obesity, obese adults who were overweight children have much more severe obesity than adults, who became obese in adulthood. Sixty percent of overweight children have at least one additional cardiovascular disease risk factor, and 25 percent have two or more. Hospitalization rates for the complications of obesity in children and adolescents have tripled.

The combination of chronic disease death and disability accounts for roughly 75 percent of the $1.3 trillion spent on health care each year in the United States. Last year, the Surgeon General's Call to Action on Obesity suggested that obesity and its complications were already costing the nation $117 billion annually. By way of comparison, obesity has roughly the same association with chronic health conditions as does 20 years of aging, and the costs of obesity were recently estimated to exceed the health care costs of smoking and problem drinking.

The rapid increases in obesity across the population and the burden of costly diseases that accompany obesity indicate that we should not ignore. The rapidity with which obesity has increased can only be explained by changes in the environment that have modified calorie intake and energy expenditure. Fast food consumption now accounts for more than 40 percent of a family's budget spent on food. Soft drink consumption supplies the average teenager with over 10 percent of their daily caloric intake. The variety of foods available has multiplied, and portion size has increased dramatically. Fewer children walk to school, and the lack of central shopping areas in our communities means that we make fewer trips on foot than we did 20 years ago. Hectic work and family schedules allow little time for physical activity. Schools struggling to improve academic achievement are dropping physical education and assigning more homework, which leaves less time for sports and physical activity. Television viewing has increased. Neighborhoods can be unsafe for walking, and parks may be unsafe for playing. Many office buildings tend to have inaccessible and uninviting stairwells that are seldom used, and many communities are built without sidewalks or bike trails to support physical activity.

Public Health Approach

Given the size of the population that we are trying to reach, we cannot rely solely upon individual interventions that target one person at a time. Instead, the prevention of obesity will require coordinated policy and environmental changes that affect large populations simultaneously. The CDC has made efforts to develop effective prevention and treatment strategies through our state obesity programs, state coordinated school health programs, partnerships with other organizations, and an applied research agenda to develop and refine new approaches.

A Coordinated Strategy to Address the Obesity Epidemic

Currently CDC funds 12 states to prevent and reduce obesity and its chronic related diseases. Our support permits states to develop and test nutrition and physical activity interventions to prevent obesity through strategies that focus on policy-level changes (e.g., States assess and rate childcare centers for nutrition and active play) or a supportive environment (e.g., competitive pricing of fruits and vegetables in school cafeterias). Examples of these approaches can be illustrated by the experience in three states.

In Massachusetts, The National Institutes of Health (NIH) funded a school-based obesity curriculum known as Planet Health. This curriculum, which integrated reduced fat, increased fruit and vegetable intake, increased physical activity, and reduced television, messages in science, math, language and social studies classes significantly reduced obesity in adolescent girls. The CDC is now supporting the expansion of this program into public, charter, and parochial school systems in Boston.

The State of Rhode Island has selected racial and ethnic minority children enrolled in public elementary schools as the target for lifelong healthy eating and physical activity behaviors to promote healthy weight, based on the CDC guidelines for school health, which were developed with input from the Department of Education. After surveying half of all elementary schools (including all schools with at least 25 percent or more Hispanic enrollment) to assess existing nutrition and physical activity programs, policies, and environmental supports in schools, the state is developing a systems-level, nutrition and physical activity intervention that will increase the number of environmental and policy supports in schools based upon the CDC guidelines for school health programs to promote lifelong physical activity and healthy eating. Selected communities with schools where at least 40 percent of the students are Hispanic/Latino and 50 percent or more of the student population is eligible for free or reduced lunch programs will be involved in the program beginning in September. Each school will tailor intervention components to fit with their school structure and population while maintaining a common purpose and shared activities across schools. Program expectations include goals for student consumption of fruits and vegetables to five daily servings and participation in moderate physical activity for 30 minutes at least five times a week.

The North Carolina Healthy Weight Initiative has involved communities and an energetic statewide task force comprised of community leaders and health professionals. The group has developed a curriculum known as "Color Me Healthy" for 4 and 5 year olds that focuses on interactive, innovative learning opportunities on eating healthy and being active. Through an innovative collaboration with the U.S. Department of Agriculture (USDA), implementation of "Color Me Healthy" is underway in 71 counties through cooperative extension and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). These programs help illustrate how CDC-funded programs translate research findings into practice, and integrate HHS activities with those of other departments.

In addition to the collaboration with state health departments, CDC also funds 20 state educational agencies through the Coordinated School Health Program. This program reaches students in elementary and secondary schools and strives to increase physical activity and improve the nutrition among our nation's young people. Through this program, the CDC awards competitive grants to State, tribal, and territorial educational agencies to:

• plan, implement, and evaluate programs, including curricula, to promote a healthy lifestyle, including programs that increase physical activity and improve the nutrition of the students at elementary and secondary schools;
• provide education and training to education professionals, including physical education, health education, and food service professionals, in State and local educational agencies;
• monitor youth lifestyle behaviors and/or programs to influence them;
• develop and implement policies to support effective implementation of school health programs at the local level; and
• build effective partnerships with other government agencies and non-governmental organizations to support effective implementation of school health programs.

Examples of these approaches can be illustrated by the experience in three states. West Virginia has adopted one of the strongest standards in the nation for school nutrition. The West Virginia Board of Education prohibits the sale or serving of the following foods at school: chewing gum, flavored ice bars, and candy bars; foods or drinks containing 40 percent or more, by weight, of sugar or other sweeteners; juice or juice products containing less than 20 percent real fruit or vegetable juice; and food(s) with more than eight grams of fat per one-ounce serving. At elementary and middle schools, soft drinks are prohibited. At elementary and middle schools, soft drinks are prohibited. In addition to implementing effective policies, the West Virginia Department of Education Office of Healthy Schools collaborated with the Office of Child Nutrition and the West Virginia Nutrition Coalition plan and delivered a week-long nutrition symposium for school food service, health education, and school health services professionals. These programs impact more than 300,000 students in a state where over 25 percent of the children ages 5�17 live in poverty.

In California, the state has focused on collaborative efforts. The California Department of Education serves a population exceeding six million students, and 63 percent of these students identify themselves as a minority ( 42 percent Hispanic, 11 percent Asian Pacific, 9 percent African American, and 1 percent American Indian/Alaskan Native). To support collaborative efforts in California, the state's Department of Education and Department of Health Services formed a joint effort called School Health Connections (SHC). SHC coordinates funding, policies, and programs within both agencies and with local school districts and health departments. SHC accomplishments include:

• Collaboration with partners, leading to the passage of legislation which establishes nutrition standards for food sold in elementary schools, prohibits the sale of carbonated beverages in middle schools, until 30 minutes after lunch is served, requires schools to post state and local laws and policies related to nutrition and physical activity, and establishes a pilot program for middle and high schools to implement nutrition standards;
• the inclusion of health in new statewide standards for teacher training;
• added physical fitness test results to local school districts' accountability report cards;
• provided training in school health, including CDC's School Health Index, reaching approximately 1200 parents and professionals in the fields of education, public health, and school health; and
• obtained $6 million for school outreach for Healthy Families and Medi-Cal for Families.

Finally, the Wisconsin Department of Public Instruction (DPI), in collaboration with several University of Wisconsin departments, instituted an annual Best Practices in Physical Activity and Health Education Symposium. This two-day staff development experience for teachers showcases exemplary school-based physical activity, physical education, and health education. Information and resources on physical education and health education, including health literacy assessment tools, were provided to all 426 school districts to guide program improvement. In addition, all Wisconsin school districts received nutrition education information and training opportunities. More than 3,200 staff were trained on the Dietary Guidelines for Americans 2000, the importance of a good breakfast, and the relationship of nutrition to learning.

CDC's coordinated school health program enables state departments of education and health to work together efficiently, respond to changing health priorities, and effectively use limited resources to meet a wide range of health needs among the state's school-aged population.

Partnerships

National or state programs alone will not succeed unless they are supported by a wide array of partnerships. Nutrition and physical activity programs must be integrated across other CDC funded state programs aimed at cancer, diabetes, and cardiovascular disease. In addition, as the North Carolina program emphasizes, nutrition and physical activity programs must be linked to other departments, such as the USDA. Groups that share concerns about the impact of obesity on other diseases, such as the American Heart Association and the American Cancer Society are natural allies in obesity prevention efforts. For example, the CDC is exploring joint training activities with the American Cancer Society around nutrition and physical activity strategies within States.

Priority Strategies

At least four behavior change strategies appear justified by the current state of our knowledge. These include the development of sophisticated marketing messages designed to increase health behaviors among youth, the promotion of breast feeding and efforts to increase its duration, reduced television viewing in children and adolescents, and increased physical activity for the population. In FY2001, Congress appropriated $125 million to develop and launch the CDC Youth Media Campaign using the same strategies used by commercial marketers to reach our target audience of 9-13 year olds. The campaign will use the best principles of marketing and communications to deliver important messages to young people about the importance of building healthy habits early in life�with the full knowledge that today's youth are very savvy about the messages they receive. The Youth Media Campaign will be launched in June of 2002 with the focus on getting kids excited about increasing the amount of physical activity in their lives, and helping their parents to see the importance of physical activity to the overall health of their kids.

Breast feeding is unquestionably the most appropriate form of feeding for most infants, and clearly reduces the incidence of acute diseases of infancy and early childhood. Recent studies of breast-feeding indicate that children who are breast-fed appear to have a reduced risk of obesity later in life. Nonetheless, only 64 percent of new mothers initiate breast feeding, and only about 29 percent have continued breast feeding six months after birth. A major research objective is to understand how to increase breast feeding rates and duration through strategies such as spouse support or worksite modifications that permit mothers to continue to feed their children breast milk after they return to work.

The prevalence of obesity has been directly related to the amount of time children and adolescents watch television, and therefore reducing television time appears to be an effective strategy to treat and prevent obesity. Nonetheless, incentives for parents to reduce the amount of time their children watch television must still be identified. Some research suggests that parental concerns about televised violence or sexuality may be more persuasive reasons than obesity prevention to control children's television time.

Increased physical activity for overweight patients reduces many of the co-morbidities associated with obesity such as hypertension, hyperlipidemia, and glucose tolerance. We now have six evidence based strategies around the promotion of physical activity. These include recommendations for physical education programs in schools, promotion of stairwell use, access and promotion of recreation facilities, social supports for physical activity, individually adapted behavior change, and community-wide campaigns.

Medical approaches are an integral part of the battle against the bulge. When 25 percent of adults are affected with obesity, the effective translation of proven strategies into approaches that can be used in primary care settings must become a high priority. We recently calculated what it would cost if all obese Americans were started on one of the two available drugs for the treatment of obesity. The costs of drug therapy were approximately the same as the direct costs of obesity. This observation indicates that conventional medical therapy for the treatment of obesity is extremely expensive. However, last year an NIH clinical trial demonstrated that diet, exercise, and modest weight loss decreased the incidence of diabetes by almost 60 percent - a far greater improvement than the pharmaceutical therapy in the comparison group. These results emphasize the importance of lifestyle modification in the treatment of prediabetes. We are currently working with several managed care organizations to begin the process of translating these approaches into strategies that can be used in primary care. In a meeting to be held this summer, we will begin the process of identifying simple and effective counseling techniques that can be used by physicians, nurse practitioners and nutritionists to help obese patients. Evaluation of these approaches will be critical.

In summary, this hearing could not have come at a more opportune time. Obesity in the United States is epidemic. The diseases caused by obesity like diabetes have also begun to increase, and are already adding to health care costs. CDC programs have begun to address the problem of obesity, but are small and just beginning. Nonetheless, comprehensive nutrition and physical activity approaches to prevent and treat obesity appear the most cost-effective strategy to reduce obesity and its complications.

Thank you for the opportunity to talk about this very critical issue. I would be happy to answer any questions the Committee may have.