Testimony

September 15, 2004

Mr. Chairman, Members of the Committee, thank you for the opportunity to participate in today's hearing. I am Dr. Ed Thompson, Chief of Public Health Practice at the Centers for Disease Control and Prevention (CDC). Today, I will present an overview of the overweight epidemic in our nation; describe the scientific information available on effective interventions to prevent overweight among various populations; and identify a number of Department of Health and Human Services (DHHS) initiatives and programs designed to combat this epidemic.

Overview of Obesity Epidemic in U.S.

In the United States, obesity has risen at an epidemic rate during the past 20 years. Nearly two-thirds of adults in the United States are overweight, and 30 percent are obese according to the National Center for Health Statistics 1999-2002 National Health and Nutrition Examination Survey (NHANES). Particularly disturbing are the dramatic increases in the prevalence of overweight children and adolescents of both sexes, with approximately 15.8 percent of children aged 6 to 11 years and 16.1 percent of adolescents aged 12 to 19 years considered overweight. The prevalence of overweight and obesity varies by gender, age, socioeconomic status, and race and ethnicity.

The prevalence of overweight and obesity varies by gender, age, socioeconomic status, and race and ethnicity.

While the increases in overweight among children and adolescents cut across all regions of the Nation, ages, and racial and ethnic groups, the prevalence of overweight is growing at a much faster rate among certain populations. A higher percent of African-American and Mexican-American youth are overweight when compared to white youth, and this disparity has grown dramatically over the past two decades. Additionally, 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.

Overweight and obesity are associated with increased morbidity and mortality. Overweight and obesity are considered risk factors for other chronic conditions such as diabetes and certain cancers, including cancers of the breast, colon, kidney, esophagus and endometrium. 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.

The primary concern of overweight and obesity is one of health and not appearance. We have already begun to see the impact of the obesity epidemic on the health of young people. While most of the death and disease associated with overweight and obesity occurs in adults, overweight children 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 both parents are 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. Individuals must have the right information to empower their lifestyle choices.

The government can support individual action by doing the following:

• 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 Secretary Tommy Thompson has made addressing the problems of overweight and obesity a top priority. Current initiatives 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 target a variety of populations including infants and breastfeeding mothers, children and adolescents, women, minorities, the elderly, the disabled, rural, and the general population.

DHHS has adopted a comprehensive, multi-component approach to address the complex epidemic of overweight among children and adolescents. DHHS 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.

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 the initiative to improve personal health and fitness and encourages all Americans to:

• Be physically active every day;
• Eat a nutritious diet;
• Get preventive screenings; and
• Make healthy choices concerning alcohol, tobacco, drugs and safety.

In 2003, Secretary Thompson 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 part of this 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, DHHS 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. efforts to promote health and prevent disorders such as obesity rests, in large part, on developing effective messages tailored to different individuals and groups. 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. 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 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 pre-teen 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 34 percent more sessions of free-time physical activity when compared to children who were unaware of VERB.

Other important 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. The 5-A-Day program seeks to increase to five 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 President's Council on Physical Fitness and Sports 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 DHHS Secretary about issues related to physical activity, fitness, and sports, and recommends programs to promote regular physical activity for the health of the nation.

Human health and disease are also influenced by factors in the overall environment. At a time when obesity is rising among children, designing and implementing environmental design solutions might help with this health challenge. Research increasingly suggests that children benefit from the opportunity to play outdoors. Planning parks near residential areas with playgrounds and sports facilities and safe routes leading to and from them can be an invaluable part of a community design strategy that is healthy and nurturing for children.

NIH and CDC have recently released a Request for Applications (RFA) on "Obesity and the Built Environment." This initiative will support studies in two specific areas related to the built environment and obesity:

• Understanding the role of the built environment in causing/exacerbating obesity and related co-morbidities; and,
• Developing, implementing, and evaluating prevention / intervention strategies that influence parameters of the built environment in order to reduce the prevalence of overweight, obesity and co-morbidities.

CDC Surveillance Efforts

CDC's surveillance efforts through the National Health and Nutrition Examination Survey (NHANES) have offered unparalleled scientific contribution to public health by producing the principal source of clinical data for the Nation with detailed interviews and physical examinations. The detailed interview includes demographic, socio-economic, dietary, and health-related questions. The examination component consists of medical and dental exams, physiological measurements and laboratory tests administered by highly trained medical personnel.

The Behavioral Risk Factor Surveillance System (BRFSS) is our nation's premier system for measuring and tracking state-level data on critical health problems and a wide variety of health-related behaviors in the U.S. The data underpin many public health policy and program decisions in states and for the nation. The BRFSS is a cross-sectional telephone survey conducted by state health departments, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam. CDC provides technical assistance to participating states and territories. For 20 years, this unique state-based system (the largest telephone-based surveillance system in the world) has provided flexible, timely, and ongoing data collection that can be tailored to meet individual state needs.

Addressing the increasing demand for local health information, CDC analyzed 2002 BRFSS data for metropolitan and micropolitan statistical areas (MMSAs). "SMART BRFSS" yielded prevalence estimates for 98 MMSAs, as well as many counties within those areas. This allows us to find out a wide range of information on different chronic diseases. For example, obesity prevalence ranges from 12.8 percent in the Bethesda-Frederick-Gaithersburg, Maryland MMSA to 29.4 percent in the Charleston, West Virginia MMSA.

The Youth Risk Behavior Surveillance System (YRBSS) was developed in 1990 to monitor priority health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth in the United States. Such behaviors include inadequate physical activity. The YRBSS includes national, state, and local school-based surveys of representative samples of 9th through 12th grade students. These surveys are conducted every two years, usually during the spring semester. The national survey, conducted by CDC, provides data representative of high school students in public and private schools in the United States.

CDC uses the data gathered from these surveillance systems to gain critical insight into identifying the obesity burden. In 2002, three states had obesity prevalence rates of 25 percent or more and all but 15 states had obesity prevalence rates of 20 percent or greater. In the state of Utah, 59.5 percent of high schools students attended a physical education class one or more days in a regular school week in 2003. In most states, less than half of high school students receive at least one day of physical education.

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

With 2004 funding, CDC supports obesity prevention programs in 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. CDC also 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, CDC is developing a mechanism to quickly deploy staff into communities, worksites and schools to facilitate evaluation of promising strategies aimed at improving nutrition, increasing physical activity, and preventing obesity. Each team will collect baseline data, and provide evaluation consultation and technical assistance, identify methodological gaps, and provide recommendations to improve the quality of program evaluation.

Other DHHS Efforts

Working groups within DHHS have recently evaluated current 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 (HRSA) 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

DHHS is collaborating with the U.S. Department of Agriculture (USDA) 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.

NIH's Obesity Research Task Force

Through its research mission, NIH is seeking to capitalize on recent scientific discoveries to further understand the forces contributing to obesity and develop strategies for prevention and treatment. The increase in obesity over the past 30 years has been fueled by complex interplay of environmental, social, economic, and behavioral factors, acting on a background of genetic susceptibility. As a result, NIH supports a broad spectrum of obesity-related research, including molecular, genetic, behavioral, environmental, clinical, and epidemiologic studies.

As the problems of overweight and obesity have grown the need for new action and research has become more evident. In response, NIH assembled a Task Force to identify areas for new research across its many institutes, and in August 2004 released the Strategic Plan for NIH Obesity Research (http://www.obesityresearch.nih.gov/About/strategic-plan.htm). This report identifies key areas for research, goals for research and strategies for achieving the goals.

The report highlights areas of research to better understand, prevent, and treat obesity. The strategic plan's goals, and strategies for achieving them, are organized into chapters organized around the following four themes:

• Research towards preventing and treating obesity through lifestyle modification;
• Research towards preventing and treating obesity through pharmacologic, surgical, or other medical approaches;
• Research towards breaking the link between obesity and its associated health conditions; and,
• Cross-cutting research topics, including health disparities, technology, fostering of interdisciplinary research teams, investigator training, translational research and education/outreach efforts.

The planning process was informed by input from external experts through meetings and workshops, through circulation of a draft of the Strategic Plan, and through posting of a draft of the Strategic Plan on the Internet for a public comment period prior to publication of a final version. The National Institute of Diabetes and Digestive and Kidney Disease's (NIDDK) Clinical Obesity Research Panel (CORP) is an important advisory group that provides expert input on obesity to the NIH. This group is composed of leading external obesity researchers and clinicians. Further, NIH's National Advisory Councils, which are groups of prominent external scientific experts and lay leaders, review and discuss strategies, in the form of initiatives, which are designed to achieve the goals of the Strategic Plan.

Tools to help schools and community-based organizations

In addition, DHHS 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, a joint product of HHS, USDA, and ED 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.

Programs to help older citizens

The Administration on Aging's (AoA) National Policy and Resource Center on Nutrition, Physical Activity and Aging was created for the purpose of increasing and improving food and nutrition services to older Americans through their caregivers at home, with community-based service providers, and in long-term care systems. The Center focuses on linking proper nutrition and physical activity as key themes in the healthy aging process. One strategy for making this link has been the development and publication of a community guide entitled, "You Can! Steps to Healthier Aging", that details a 12-week program to help older Americans "eat better" and "move more." The Center is awarding 10 mini-grants to local communities to implement the You Can! Program in 2004.

AoA provides funding to states to implement health promotion and disease prevention activities. Educational information is disseminated through Senior Centers, congregate meal sites, and home-delivered meal programs. Health screening and risk assessment activities including hypertension, glaucoma, hearing, nutrition screening, cholesterol, vision, diabetes, bone density, and others are also provided. Physical activity and fitness programs are provided along with education about the prevention and reduction of alcohol, substance abuse, and smoking. Further, this AoA program emphasizes the importance of appropriately managing medications.

Conclusion

Successfully combating the overweight epidemic in our nation 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. DHHS 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?

DHHS agencies will lead the Nation in conducting the research necessary to answer these questions. In October, DHHS and USDA will host the National Obesity Prevention Conference addressing this important public health concern. The objective of the conference is to learn from past and current research identifying steps we can take to prevent further increase in the prevalence and severity of obesity, and to lead to behavioral changes for a healthier U.S.

We are learning a great deal about effective strategies for promoting physical activity and healthy eating. We know that no one strategy alone will be sufficient. Our chances for success will be greatest if we use multiple strategies to address numerous factors that contribute to caloric imbalance and if we involve various sectors of society at the community, state, and national levels. DHHS is leading the national effort to combat the overweight epidemic in our nation through a comprehensive, multi-faceted, multi-level approach. We are committed to doing all that we can to help our nation 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 and would be happy to answer your questions.

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