Testimony

June 16, 2004

Introduction

Mr. Chairman, Members of the Committee, thank you for the opportunity to participate in today's hearing. I am Dr. Howell Wechsler, Acting Director of the Division of Adolescent and School Health at the Centers for Disease Control and Prevention (CDC), which is part of the U.S. Department of Health and Human Services. Today, I will present an overview of the overweight epidemic among children and adolescents; describe the scientific information available on effective interventions to prevent overweight among young people; and identify a number of Department of Health and Human Services (HHS) initiatives and programs designed to combat this epidemic.

The National Institutes of Health defines obesity and overweight using a Body Mass Index (BMI), which is a calculation of a person's weight in kilograms divided by the square of their height in meters. Health professionals often use a gender and age specific BMI "growth chart" to help them assess whether a child or adolescent is overweight. Children are considered overweight if they are at or above the 95th percentile of the sex-specific BMI for age growth charts. Doctors and other health care professionals are the best people to determine whether an overweight child or adolescent's weight and growth patterns place the individual at risk for health problems. At the current time, there is no definition of obesity for children and adolescents, because BMI is not a reliable measure of fatness for children, especially across varying ages and degrees of maturity, in contrast to adults who have already reached their peak height. There is also concern related to the potential stigma associated with using the term "obesity" for children.

Overview of Overweight Among Children and Adolescents in U.S.

In the United States, obesity and overweight has risen at an epidemic rate during the past 20 years. The prevalence of overweight has more than doubled among children and has tripled among adolescents since 1980. Approximately 15.3 percent of children aged 6 to 11 years and 15.5 percent of adolescents aged 12 to 19 years were overweight in 1999-2000. There are no signs that the rapid increase in overweight seen over the past two decades is abating. The latest data, which cover the period from 1999-2002, is being released today by CDC in the Journal of the American Medical Association.

The increases in overweight among children and adolescents cut across all regions of the Nation, ages, and racial and ethnic groups. However, the prevalence of overweight has been growing at a much faster rate among certain populations. For example, more African-American and Mexican-American youth are overweight compared to white youth, and this disparity has grown dramatically over the past two decades. An economic disparity in the prevalence of overweight is seen among white adolescents: those from lower income families have a greater prevalence of overweight compared with white adolescents from higher income families.

The primary concern of overweight and obesity is one of health and not appearance. An estimated 400,000 adult deaths each year in the U.S. are associated with obesity. Total costs (medical costs and days lost from work because of illness, disability or premature death) from obesity in 2000 were estimated to be $117 billion.

We have already begun to see the impact of the obesity epidemic on the health of young people. Although most of the death and disease associated with overweight and obesity occurs in adults, children who are overweight often develop risk factors for diseases such as type 2 diabetes, high blood pressure, and elevated cholesterol levels. Sixty percent of overweight children have at least one risk factor for cardiovascular disease, in addition to overweight, and 25 percent have two or more. Type 2 diabetes, which is strongly associated with obesity, was virtually unknown in children and adolescents 10 years ago; today, it accounts for almost 50 percent of new cases of diabetes among youth in some communities. A CDC report predicted that one in three Americans born in 2000 will develop diabetes during his or her lifetime. Childhood overweight is also associated with discrimination, poor self-esteem, and depression.

Furthermore, overweight adolescents have a 70 percent chance of becoming overweight or obese adults. This increases to 80 percent if one or more parent is overweight or obese. Adults who are overweight or obese are at increased risk for premature death, heart disease, type 2 diabetes, certain types of cancer, breathing problems, arthritis, and psychological problems, such as depression. One final concern is that childhood overweight that persists into adulthood is typically more severe than overweight or obesity that develops during adulthood.

Overweight and obesity represent a major long-term public health crisis. If it is not reversed, the gains in life expectancy and quality of life seen in recent decades will erode, and more health-related costs will burden the nation.

Government's Role in Combating the Obesity Epidemic

Eating a healthy diet and increasing physical activity reduces weight which is shown to reduce the risk for many chronic diseases. Often small changes - such as physical activity for 30 minutes a day or consuming 100 fewer calories a day - can result in large health benefits. In order for individuals to take action, they must have the right information to empower their lifestyle choices. The government can support individual action by:

• Providing leadership;
• Establishing a framework for understanding issues related to overweight and obesity;
• Coalescing and coordinating efforts to address the issues;
• Developing clear, coherent and effective health messages to ensure that consumers have accurate and adequate information to make informed decisions about improving their health;
• Identifying and addressing research gaps;
• Bringing diverse stakeholders together to address the epidemic (e.g., food industry, consumer organizations and the medical community);
• Coordinating private/public campaigns;
• Providing training and education materials to address the epidemic; and
• Working to improve the health-promoting nature of the environments in which individuals make their decisions.

HHS has made addressing the problems of overweight and obesity top priorities for the Department. In fact, HHS has a large number of current initiatives and programs underway to address these issues. They include programs in education, communication and outreach, intervention, diet and nutrition, physical activity and fitness, disease surveillance, research, clinical preventive services and therapeutics, and policy and web-based tools. These programs are targeted to a variety of populations including infants and breastfeeding mothers, children and adolescents, women, minorities, the elderly, the disabled, rural, and the general population.

HHS has adopted a comprehensive, multi-component approach to address the complex epidemic of obesity among children and adolescents. HHS strategies include:

• Providing strong, national leadership
• Developing and delivering clear, coherent, and effective health messages to ensure that consumers have accurate and adequate information to make informed decisions about improving their health;
• Monitoring the problem and programs to address the problem so that we can better understand its causes, consequences, and how it changes over time;
• Identifying and addressing research gaps;
Synthesizing research findings to identify effective policies and programs;
• Developing and disseminating tools to help schools and community-based organizations implement effective policies and programs; and
• Helping national, state, and local agencies and organizations implement effective programs.

Department of Health and Human Services Steps Initiative

In June 2002, President Bush launched the HealthierUS initiative designed to help Americans, especially children, live longer, better, and healthier lives. The President's HealthierUS initiative helps Americans take steps to improve personal health and fitness and encourages all Americans to: 1) be physically active every day; 2) eat a nutritious diet; 3) get preventive screenings; and 4) make healthy choices concerning alcohol, tobacco, drugs and safety.

In 2003, Tommy Thompson, Secretary of the Department of Health and Human Services, further advanced the President's initiative by introducing Steps to a HealthierUS (Steps). At the heart of this program lies both personal responsibility for the choices Americans make and social responsibility to ensure that policy makers support programs that foster healthy behaviors and prevent disease. The Steps initiative envisions a healthy, strong, U.S. population supported by a health care system in which diseases are prevented when possible, controlled when necessary, and treated when appropriate.

The Steps Cooperative Agreement Program is one part of Secretary Thompson's larger Steps initiative. This program aims to help Americans live longer, better, and healthier lives by reducing the burden of diabetes, obesity, and asthma and addressing three related risk factors - physical inactivity, poor nutrition, and tobacco use. In FY 2003, $15 million was provided to 23 communities to support innovative community-based programs that are proven effective in preventing and controlling chronic diseases. In FY 2004, $44 million will be used to increase funding to existing Steps communities, fund new communities, and fund one or two national organizations to enhance the capacity of Steps communities.

As part of the Steps initiative, HHS also recently released a report titled Prevention: A Blueprint for Action, which outlines simple steps that individuals and interested groups can take to promote healthy lifestyles and encourage healthy behavior. The Department's efforts to promote health and prevent disorders such as obesity rests, in large part, on developing effective messages that are appropriate for individuals and groups in ways that they can understand and act upon. An example of this is the CDC's youth media campaign demonstration, "VERB. It's what you do." VERB's goal has been to promote social norms that support physical activity and portray fitness as fun and healthy. HHS/CDC has enlisted partner organizations in the campaign, such as 4-H, Boys and Girls Clubs and the National Hockey League to brand the VERB message and make it appealing to its pre-teen audience. VERB also reaches out to parents and other adults influential to young people, encouraging them to support and participate in physical activity with pre-teens.

Campaign strategies include multimedia advertising and marketing promotions using television, radio, print, and Web sites; contests and community events; and partnerships with youth organizations, schools, national professional associations, and entertainment media that are popular with youth. Reported preteen (or "tween") awareness of VERB is high at 74 percent, with 90 percent of these youth understanding the campaign's messages. After one year, campaign impact has been demonstrated by reports of increased free-time physical activity among several important population subgroups, including the nation's 10 million tween girls, 8.6 million 9-10 year olds, and 6 million tweens from low- to moderate-income households. For example, after one year of the campaign, the average 9-10 year old in the nation engaged in more sessions of free-time physical activity when compared to children who were unaware of VERB.

Other important HHS programs that communicate nutrition and physical activity messages to the American public are the National Cancer Institute's 5 A Day for Better Health Program and the President's Council on Physical Fitness and Sports (PCPFS). The 5 A Day program seeks to increase to 5 or more the number of daily servings Americans eat of fruits and vegetables. In addition to its widely known slogan, the 5 A Day program reaches many individuals through health care provider networks, the internet, and print media. It also has sponsored the development and evaluation of a number of school-based interventions to promote fruit and vegetable consumption among children and adolescents.

The PCPFS promotes physical activity for all ages, backgrounds and abilities with information and publications (www.fitness.gov) and physical activity/fitness motivational awards programs (www.presidentschallenge.org). The Council advises the President and the Secretary of HHS about issues related to physical activity, fitness, and sports, and recommends programs to promote regular physical activity for the health of the nation.

CDC Surveillance Efforts

Through its ongoing National Health and Nutrition Examination Survey, CDC produces nationally representative data on the prevalence of overweight among children and adolescents based on measured height and weight, as well as on their dietary and physical activity behaviors. In addition, CDC's biennial Youth Risk Behavior Survey provides national, state, and city data on self-reported height and weight, physical activity, and dietary behaviors among high school students.

CDC's School Health Policies and Program Study (SHPPS) is a national survey periodically conducted to assess school health policies and programs of state education agencies and of nationally representative samples of school districts, schools, and health and physical education classrooms. SHPPS provides national data on what schools are doing in relation to physical education, after school physical activity programs, recess, nutrition education, school food service, and vending machine policies and practices. CDC's School Health Profiles survey, conducted every other year, tells us about the extent to which schools are implementing physical activity and nutrition-related policies and practices in different states and cities.

CDC's National Nutrition and Physical Activity Program to Prevent Obesity

With 2004 funding, the CDC will support obesity prevention programs in a total of 28 states. Of these, 23 states will be funded at the capacity-building level to hire staff with expertise in public health nutrition and physical activity, build broad based coalitions, develop state plans, identify community resources and gaps, implement small-scale interventions, and work to raise public health awareness of changes needed to help state residents achieve and maintain a healthy weight. The other five states are funded at the basic-implementation level to put their state plans into action, conduct and evaluate nutrition and physical activity interventions, train health care and public health professionals, provide grants to communities, make environmental changes, and strengthen obesity prevention programs in community settings. In addition, CDC provides funding to 23 states for the implementation of school-based policies and programs to help young people avoid behaviors that increase their risk for obesity specifically unhealthy eating and inadequate physical activity.

Additionally, the CDC is developing a mechanism to quickly deploy staff (rapid deployment teams) into communities, worksites and schools to facilitate evaluation of promising strategies aimed at improving nutrition, increasing physical activity, and preventing obesity. Each team would collect baseline data, and provide evaluation consultation and technical assistance, identify methodologic gaps, and provide recommendations to improve the quality of program evaluation.

Other HHS Efforts

Working groups within the Department's agencies have recently evaluated current HHS programs and activities, made recommendations to better coordinate these efforts, and identified areas of opportunity for new initiatives. Two recent major initiatives tied to obesity are the Food and Drug Administration's (FDA) Obesity Working Group, which will advise the Agency on innovative ways to deal with the increase in obesity and identify ways to help consumers lead healthier lives through better nutrition, and the National Institute of Health's (NIH) development of an Obesity Research Task Force, to develop a strategic plan for obesity research.

This past year the FDA made a major change in the nutrition label on foods to include a separate listing of trans fatty acids. This was the first significant change in the Nutrition Facts panel since it was established in 1993.

The FDA has also undertaken a broad effort to crack down on misleading information and/or unsafe dietary supplements, and has proposed new regulations to establish good manufacturing practice requirements for dietary supplements. FDA has focused its enforcement efforts over the past year to ensure consumers are not being harmed as a result of claims that overstate the effectiveness of dietary supplement products. The Agency took steps to remove dietary supplements containing ephedrine alkaloids from the market. These products were extensively promoted for aiding weight control and boosting sports performance and energy. The totality of the available data showed little evidence of benefit from dietary supplements containing ephedrine alkaloids except for modest, short-term weight loss insufficient to improve health, while confirming that ephedrine alkaloids raise blood pressure and otherwise stress the circulatory system. These effects are linked to significant adverse health outcomes, including heart attack and stroke. In March of this year, the Agency announced various efforts to crack down on products containing androstenedione, or "andro." This class of products poses substantial safety risks to all Americans, particularly our nation's youth and athletes.

One of the key messages of this effort is that there are no safe quick fixes when it comes to losing weight and improving athletic performance, and it is only through proper diet, nutrition and exercise that we can improve our physical performance and, more importantly, maintain and improve our health.

Also, in the school setting, the Health Resources and Services Administration's Healthy Schools, Healthy Communities program promotes and establishes comprehensive school-based health centers to improve the health of at-risk school aged children. Services provided by the centers include nutrition education and counseling, support groups for overweight children, dietary surveillance, and nutrition screening.

National Dietary Guidelines

HHS is collaborating with the U.S. Department of Agriculture to review the Dietary Guidelines that were published in 2000 and to draft new 2005 Dietary Guidelines for Americans. In light of the growing number of overweight and obese Americans, a major focus of the new guidelines will be providing guidance to the public on maintaining a healthy weight and creating lifestyles that balance the number of calories eaten with the number of calories expended. These guidelines must: (1) contain nutritional and dietary information and guidelines for the general public, (2) be based on the preponderance of scientific and medical knowledge current at the time of publication, and (3) be promoted by each Federal Agency involved in a Federal food, nutrition, or health program.

Strategies for Combating Overweight in Children

Overweight and obesity result from an imbalance between caloric intake and caloric expenditure. Many factors have contributed to the unfavorable trends in physical activity and nutrition that have fueled the obesity epidemic. Consequently, there will be no silver bullet, no single change strategy to solve these problems. Multiple strategies addressing multiple factors will be needed to successfully combat the obesity epidemic.

Reviews of research conducted to date indicate that there are at least three behavioral strategies for reducing rates of overweight and obesity that appear to be justified by the current state of knowledge. These are: (1) increased physical activity for the population, (2) reduced sedentary behaviors, such as television viewing and video gaming, for children and adolescents, and (3) the promotion of breast feeding and efforts to increase its duration.

Increased physical activity for overweight patients reduces many of the co-morbidities associated with obesity such as hypertension, hyperlipidemia, and glucose intolerance; maintains weight after weight loss; and prevents weight gain. The dose of physical activity necessary to prevent weight gain among normal or overweight children, adolescents, or adults has not been established, although one hour of daily, moderate intensity physical activity appears required for weight maintenance in adults after weight loss.

A factor in the prevalence of overweight among our youth may be the amount of time children and adolescents are sedentary, watching television or playing video games, for example. One school-based study demonstrated a two percent decrease in overweight as a result of a curriculum that included reduced television time. A second school-based study demonstrated reduced rates of weight gain in children who reduced television time.

Breastfeeding is the most appropriate form of feeding for most infants and clearly reduces the incidence of acute diseases of infancy and early childhood. In addition, recent studies indicate that breastfeeding reduces the risk of childhood overweight by 15-20 percent.

While we have good ideas about the types of behaviors we need to promote, the critical challenge before us is to identify how we can effectively help young people and their families to adopt these behaviors.

Tools to help schools and community-based organizations

HHS has developed, and is continuing to develop, a variety of tools that schools can use to implement policies and practices recommended by the CDC guidelines. These include:

• CDC's School Health Index for Physical Activity and Healthy Eating, a widely used self-assessment and planning tool that enables schools to identify the strengths and weaknesses of their health promotion policies and programs, develop an action plan for improving student health, and involve teachers, parents, students, and the community in improving school policies and programs.

• Fit Healthy and Ready to Learn, a school health policy guide, developed with CDC support by the National Association of State Boards of Education, that provides education policymakers and administrators with sample physical activity and nutrition policies and information to support the policies.

• CDC's Building a Healthier Future Through School Health Programs describes promising practices that states should consider when planning school-based policies and programs to help young people avoid behaviors that increase their risk for obesity and chronic disease, especially tobacco use, unhealthy eating, and inadequate physical activity.

• Power of Choice, an after-school program jointly developed by FDA and the US Department of Agriculture (USDA) that guides pre-teens toward a healthier lifestyle by motivating and empowering them to make better food and physical activity choices in real-life settings.

• Fruit and Vegetables Galore, developed by USDA in collaboration with HHS, provides tips to school foodservice professionals on planning, purchasing, preparing, presenting, and promoting fruits and vegetables. It also includes suggestions for working with teachers by providing them with teaching tools and by supporting their educational efforts, making daily meal offerings competitive with other commercial options available to students, and getting students excited about healthful eating.

• Kids Walk to School, a user-friendly manual developed by CDC that provides information and resources for community partners to increase opportunities for daily physical activity by encouraging children to walk to and from school in groups accompanied by adults and by encouraging collaboration among partners to create an environment supportive of walking and bicycling to school safely. In addition, HHS agencies are developing important new tools, to be released in the coming months that will help schools promote healthy eating and physical activity.

• Making It Happen - School Nutrition Success Stories (MIH), a joint product of CDC and USDA, tells the stories of 32 schools and school districts that have implemented innovative strategies to improve the nutritional quality of foods and beverages offered and sold on school campuses. The most consistent theme emerging from these case studies is that students will buy and consume healthful foods and beverages-and schools can make money from healthful options.

• The Health Education Curriculum Analysis Tool is a user-friendly checklist designed by CDC to help schools select or develop curricula based on the extent to which they have characteristics that research has identified as being critical for leading to positive effects on youth health behaviors. The companion Physical Education Curriculum Analysis Tool will help school districts develop state-of-the-art physical education curriculum based on insights gained from research and best practice.

• Media Smart Youth: Food, Fitness, and Fun is a curriculum with supporting materials developed by the National Institute of Child Health and Human Development for youth ages 11-13 years old. It is designed to create awareness of the role that media play in shaping values concerning physical activity and nutrition, while building skills to encourage critical thinking, healthy lifestyle choices, and informed decision making, now and in their future.

CONCLUSION

Successfully combating the overweight epidemic among children and adults will require the involvement of many sectors and levels of society. Although national initiatives can play an important role, they are not sufficient by themselves. Community-based initiatives are critical for reaching Americans where they live, work, go to school, and play. State-level programs are critical for supporting and disseminating community-based activities. HHS is implementing a comprehensive approach to reach the American people through these various levels.

There is a great deal more that we need to learn about intervention strategies to prevent overweight among children and adolescents. Key research questions that need to be addressed include:

• Which are the most important behaviors to target to influence overweight and obesity?
• Which mediating variables should be targeted to influence obesity-related behaviors?
• Which are the types of interventions that have the greatest impact on the most critical mediating variables and behaviors?
• How do we translate efficacy study findings into real-world policies and programs?
• How do we effectively and efficiently disseminate effective policies and programs?
• Do the effects of overweight and obesity prevention policies and programs last over time?

CDC, NIH and other HHS agencies will lead the Nation in conducting the research necessary to answer these questions.

We have, however, learned a great deal about effective strategies for promoting physical activity and healthy eating among young people. We know that no one strategy alone will be sufficient and that our chances for success will be greater if we use multiple strategies to address multiple factors that contribute to caloric imbalance and if we involve multiple sectors of society at the community, state, and national levels. HHS is leading the national effort to combat the overweight epidemic in children through a comprehensive, multi-faceted, multi-level approach. We are committed to doing all that we can to help our young people enjoy good health now and for a lifetime.

I thank you for your interest and the opportunity to share information about strategies to combat the overweight epidemic in children, and would be happy to answer your questions.

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