Urgent Call for a Nationwide Public Health Infrastructure and Action to Reverse the Obesity Epidemic

The United Nations in 2004 adopted a global strategy on diet, physical activity and health that urged its member states to adopt sweeping efforts that included leadership, strategic action plans, public education, agriculture policy and multi-sector approaches in communities, among government agencies and with private interests.1 This action followed an extensive review that described the worldwide threat of non-communicable diseases in developed and developing countries.2

The Global Strategy was endorsed by the American Public Health Association (APHA).3 Early in 2005, the United States government adopted an aggressive, evidence-based dietary guidance policy aimed at improving health, preventing major chronic diseases and reversing the nation's obesity epidemic.4 The guidance aims to reshape the American diet and significantly increase daily physical activity. Fruits, vegetables, whole grains, low-fat milk products and leaner animal protein sources would replace over-consumption of low-nutrient, high-calorie processed foods. Moderate physical activity of at least 30 minutes for adults and 60 minutes for children on most days of the week would improve the health of most Americans, while at least 60-90 minutes of physical activity on most days would help with weight loss or prevent regaining weight.

Healthy People 2010 outlines objectives to reduce the proportion of children, adolescents (ages 6-19), and adults (age 20 years and older) who are either overweight or obese to at least 5 percent for youth and 15 percent for adults.5 Alarmingly, in 2003-2004, 17.1 percent of children and adolescents were overweight and 32.2 percent of adults were obese.6 Minorities suffer disproportionate levels of obesity. The prevalence of obesity for ages 20 years and older for black (non-Hispanic), Mexican American and white (non-Hispanic) are 45.0 percent, 36.8 percent, and 30.6 percent respectively.6

Obesity-attributable health care costs totaled over $75 billion in 2000, split nearly evenly between Medicare/Medicaid and private health care, straining the federal budget, state legislatures, and business.7 Rising obesity rates account for 27 percent of the increase in per capita health spending between 1987 and 2001,8 driving up health insurance premiums and draining profits throughout the country. Poor diet, physical inactivity, and obesity combined have a negative health impact similar to tobacco use.9 If negative trends continue, today's children may live shorter lives, potentially reversing gains in lifespan achieved over the past century.10 Adults and children of color or living in poverty are the most severely affected.10

While the financial costs of obesity have a large impact on the cost of adult health care and lost work productivity, the long-term consequences are most dire for children.10 Other financial concerns include substantial costs that will be incurred in the design, construction and operation of buildings and other built environment infrastructure due to the number of individuals who are obese, overweight or physically unfit. Worldwide, nations are being urged to take action now and organize themselves to introduce a wide range of interventions to avoid the otherwise inevitable human and economic costs of chronic disease attributable to poor diet, physical inactivity and tobacco use.11

APHA acknowledges that many organizations have called for action12-20 but recognizes that as yet, no cohesive leadership has emerged in the United States to provide the inspired, urgent action required to reverse an epidemic of these proportions. In addition, no national action plan for achieving these critical public health improvements has been formulated.

Therefore, APHA calls for the immediate mobilization of governmental, public, and private agencies to coordinate actions to reverse the obesity epidemic, working toward achieving the 2005 Dietary Guidelines for Americans as a means to begin reversing obesity rates as outlined in Healthy People 2010. This will require a new vision and a mix of interventions that together amount to a comprehensive, social ecological approach.21 Reversing today's trends cannot be done for free and will require resource re-allocation by stakeholders at the national, state and local levels.

Therefore, APHA supports the mobilization of federal, state, and local governments working together to create strong public/private infrastructures and calls for the following:

1. Identification of the U.S. Department of Health and Human Services as the lead federal agency to convene a high-level task force: to ensure coordinated budgets, policies and program requirements; to establish effective interdepartmental collaboration for action among at least the Departments of Agriculture, Transportation, and Education;10 and to establish task forces with similar membership in state government to work with non-profit and business sectors and lead a coordinated effort to address obesity in the United States.
2. Sufficient funding for the Centers for Disease Control and Prevention to support a leadership infrastructure and state plan for nutrition and physical activity in all states, tribes and territories in order to provide comprehensive and coordinated nutrition and physical activity program planning21 and services in communities, schools, health care facilities, worksites and media/communication settings. 
3. Policy measures at the federal, state and local levels that modify agriculture, food, transportation, community development, land use, and recreation practices, addresses the development of model building codes and safety standards and funding to improve social and physical environments restricts the advertisement of unhealthy food products and help establish a marketplace that makes healthy eating and regular physical activity easy, affordable choices for all Americans.
4. Mass communications campaigns22 that promote healthy eating and physical activity, educate the public, outreach into diverse communities with appropriate cultural specificity, modify public opinion, expose adverse environmental conditions, reveal economic drivers, challenge unhealthy norms, provoke examination of factors that drive marketplace choices, support communities, and otherwise empower consumers to improve their own environments.
5. Enforcement of laws, ordinances and policies at the federal, state and local levels that support healthy eating and physical activity, such as those for federal nutrition assistance programs, school nutrition and physical education wellness policies, zoning, smart growth, redevelopment, and transportation;
6. Surveillance, applied research and evaluation systems that offer timely and responsive information to support planning, drive program operations, investigate new developments, track and report progress and identify best practices;
7. A coordinated, action-oriented research plan among the National Institutes of Health, Centers for Disease Control and Prevention, and the U.S. Department of Agriculture to support state and local interventions and address disparities in the prevalence of obesity among racial and ethnic, gender, socioeconomic, and age groups;23 and
8. Adequate funding for comprehensive obesity-related interventions achieved through a combination of: improved use of federal categorical programs by states and localities; resource redirection by public, non-profit and business sectors, including replacement of unhealthy products and marketing with positive campaigns by the food industry; and the development of new funding streams at the national, state and local levels, ultimately reaching with amounts at least equivalent to those recommended for tobacco control, a quantifiably equivalent health risk.24

References

1. World Health Organization (2004). Global Strategy on Diet, Physical Activity and Health, Fifty-Seventh World Health Assembly, WHA57.17, Geneva, Switzerland.
2. Joint FAO/WHO Expert Consultation (2003). Diet, Nutrition and the Prevention of Chronic Diseases, WHO Technical Report Series 916, World Health Organization, Geneva, Switzerland.
3. American Public Health Association (2004). Supporting the WHO Global Strategy on Diet, Physical Activity and Health. LB04-3, American Public Health Association, Washington, D.C.
4. U.S. Department of Health and Human Services and U.S. Department of Agriculture (2005). Dietary Guidelines for Americans 2005. www.healthierus.gov/dietaryguidelines.
5. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition in Two Volumes). Washington, D.C,: January, 2000.
6. www.health.gov/healthypeople.
7. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of Overweight and Obesity in the United States, 1999-2004. JAMA 295; 1549-1555. 2006
8. Finkelstein EA, Fiebelkorn IC, Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obesity Research 12(1); 1-7, 2004.
9. Thorpe KE, Florence DS, Howard DH and Joski P(2004). Trends: The impact of obesity on rising medical spending. Health Affairs http://content.healthaffairs.org/cgi/content/abstract;hlthaff.w4.480.
10. Mokdad AH, Marks JS, Stroup DF and Gerberding JL (2004). Actual causes of death in the United States, 2000. JAMA 291(10):1238-1245.
11. Committee on Prevention of Obesity in Children and Youth (2004). Preventing Childhood Obesity: Health in the Balance. Institute of Medicine of the National Academies, the National Academies Press, Washington, D.C. www.nap.edu
12. World Health Organization (2005). Preventing Chronic Diseases: A Vital Investimant. World Health Organization, 20 Avenue Appia, CH-1211, Geneva.27, Switzerland..
13. Food Research and Action Center/America's Second Harvest (2000). State of the States: A Profile of Food and Nutrition Programs Across the Nation. Food Research and Action Center, Washington, DC www.frac.org and America's Second Harvest, Chicago, IL www.secondharvest.org
14. Food and Nutrition Service (2000). Food and Nutrition Service Strategic Plan, 2000-2005. U.S. Department of Agriculture, Washington, D.C.
15. National Cancer Institute (2000) 5 A Day for Better Health Program Evaluation Report http://cancercontrol.cancer.gov/5aday_12-4-00.pdf (Accessed on Mar 15, 2006).
16. Government Accounting Office (2002). Fruits and Vegetables: Enhanced Federal Efforts to Increase Consumption Could Yield Health Benefits for Americans. Report to Congressional Requestors. GAO-02-657, Washington, D.C.
17. Trust for America's Health (2005). F as in Fat: How Obesity Policies Are Failing in America. Issue Report, Washington, D.C. http://healthyamericans.org/reports/obesity2005/Obesity2005Report.pdf
18. Fruit and Vegetable Environment, Policy and Pricing Workshop (2004). Preventive Medicine 38, Supplement 2, The Institute for Cancer Prevention and Elsevier Inc.
19. United States General Accounting Office Report on the Committee on Agriculture, Nutrition, and Forestry U.S. Senate (2004). Nutrition Education. USDA Provides Services through Multiple Programs, but Stronger Linkages among Efforts Are Needed. 
20. Trust for America's Health (2004). F as in Fat: How Obesity Policies Are Failing in America. Issue Report, Washington, D.C. www.healthyamericans.org
21. Institute of Medicine of the National Academies (2006) Overview of the IOM Report on Food Marketing to Children and Youth: Threat or Opportunity? Fact Sheet. 
22. Gregory, S (Ed)(2002). Guidelines for Comprehensive Programs to Promote Healthy Eating and Physical Activity. Nutrition and Physical Activity Work Group. Human Kinetics, Champaign, IL www.HumanKinetics.com
23. Huhman M, Potter LD, Wong FL, Banspach SW, Heitzler CD. Effects of a Mass Media Campaign to Increase Physical Activity Among Children: Year-1 Results of the VERB Campaign. Pediatrics 116: 277-284, 2005.
24. U.S. Department of Health and Human Services. The Surgeon General's Call To Action To Prevent and Decrease Overweight and Obesity.(Rockville, MD): U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, D.C. http://www.surgeongeneral.gov/library
25. Office on Smoking and Health (1999). Best Practices for Comprehensive Tobacco Control Programs. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, GA.