Prevention and Reduction of Obesity in the United States - Postion Statement

Two-thirds of the U.S. population is obese or overweight.¹ One-third of U.S. children are overweight or at risk of being overweight.² Being obese or overweight can lead to chronic diseases such as diabetes, cancer and heart disease. This epidemic costs the nation $147 billion per year, in addition to other social and emotional costs.³ Governments and the private sector bear much of this burden; approximately 50 percent of obesity-related costs are paid through Medicare and Medicaid⁴, while businesses spend about $12.7 billion annually on obesity-related illnesses through health insurance, disability, and paid sick leave.⁵  

The causes of obesity are diverse and complex, including easy access to unhealthy foods in restaurants, schools, and worksites, lack of physical activity and policy and environmental factors that do not support healthy lifestyles.⁶ Social determinants of health, including economic and social conditions such as poverty, influence the health of populations and contribute to obesity.⁷ Populations disproportionally affected by obesity include African American, Native American, Native Hawaiian/Pacific Islander and Latino populations. Health inequities should be specifically addressed in obesity prevention efforts. Indeed, these underlying disparities have great costs to the American people as well. According to the Joint Center of Political and Economic Studies report, the indirect costs of health inequities in the US are $1.24 trillion between 2003 and 2006.⁸ ASTHO is supporting state and territorial health agencies (S/THAs) to address the root causes of obesity and change the culture in the United States so that healthier lifestyles are supported and the healthy choice is the easy choice for everyone.

A shift in the current system and culture is necessary to reverse the obesity epidemic.

State and territorial health agencies, along with federal, state, and local governments, can provide the leadership necessary to prevent and reduce obesity, improving the health outcomes and quality of life of all Americans. National and federal strategies such as the National Prevention Strategy⁹ and the Institute of Medicine’s Accelerating Progress in Obesity Prevention Report¹⁰, serve as a roadmap for state health agencies to address healthy eating and active living policies and programs across various sectors. Programs, such as Community Transformation Grants and Coordinated Chronic Disease Programs also provide the funding and infrastructure needed to support healthy and safe communities that provide access to healthy foods, physical activity and clinical preventive services.

SPECIFIC RECOMMENDATIONS

ASTHO supports infrastructure for state and territorial health agencies to address obesity through:

• State health agency leadership and infrastructure that fosters engagement of multiple sectors to provide comprehensive systematic change.
• State health agency programs that have the ability to address healthy eating and active living policies and programs with an effective, coordinated, sustainable infrastructure.
• Partnerships across state, territorial, federal, and local governments, community groups, and health care systems that provide safe, culturally competent and appropriate programs, affect policy, and implement initiatives, cross-cutting programs, and consistent targeted messages to transform communities.
• Partnerships within state and territorial health agencies to support coordination among all programs such as nutrition and physical activity, heart disease and stroke prevention, injury and violence prevention, diabetes prevention and control, maternal and child health, the Behavioral Risk Factor Surveillance System, and other related chronic disease prevention programs. 
• Partnerships across state and territorial health agencies that support obesity prevention policy and environmental change in cooperation with agencies overseeing education, transportation, housing, agriculture, healthcare, and other sectors.
• Coordinated chronic disease programs that support infrastructure for all programs to have adequate and coordinated leadership that supports communications, evaluation, surveillance, and management of related programs. 
• State leadership in the adoption of healthy workplace policies within health agencies and throughout state government by implementing health risk assessments; healthy food procurement policies that include agency food purchasing, events and meetings, vending machines, and cafeterias; and other incentives for employees to improve their health.

ASTHO supports policy and environmental changes across the lifespan through:

• Policy, programmatic, and other system changes in accordance with the Dietary Guidelines for Americans¹¹ and the Physical Activity Guidelines for Americans¹² to ensure that healthier food and physical activity are accessible to all populations and consider regulatory approaches to implement and enforce obesity prevention measures.

Breastfeeding policies that support breastfeeding in the Women, Infants, and Children program; encourage and support hospitals to pass Baby-Friendly Hospital practices*; and support adequate time and space for breastfeeding or expressing milk in the workplace.

• Early childhood education policies that support access to healthy foods and beverages through the Child and Adult Food Care Program; state child care licensing standards that includes nutrition and wellness guidelines, age-appropriate physical activity, limit the use of screen time, and serve meals and snacks that meet nutrition guidelines.
• Education policies that support healthy students through coordinated school health programs; adequate time and intensity of physical education and activity; access to healthy foods and beverages through the National School Lunch and Breakfast Program and throughout the school day that meet updated standards developed by the U.S. Department of Agriculture and the Dietary Guidelines 2010; implementation of school wellness policies; farm to school programs; and joint use agreements.
• Food marketing guidelines developed by the Interagency Working Group that restrict the marketing of high energy dense foods and sugar-sweetened beverages to children under the age of 18, near schools or other places where youth gather.
• Nutrition labeling in restaurants and similar establishments and vending policies that provide consumers with appropriate information at point of purchase; support for state health agencies to provide the regulatory structure to enforce these mandates.
• Worksite wellness policies and accreditation programs that promote a healthy work environment, encourage incentive programs for individuals to maintain healthy weight; support the inclusion of preventive services in routine clinical practice, including reimbursement for proven clinical preventive services; support healthy foods and physical activity at meetings, events, and in vending machines; and encourage breastfeeding or expressing milk in the workplace.  
• Agriculture policies that shift federal subsidy support from highly processed foods to less processed foods that are low in saturated and trans fats, cholesterol, sodium, and sugar; increase access to affordable fresh fruit and vegetables through commodity programs; support healthy foods in food assistance programs; expand farmers markets and encourage the use of electronic benefit transfer at farmers markets; support fresh fruit and vegetable distribution to schools; and address the problem of food deserts.
• Transportation policies that support partnerships with planners, transportation, and developers; create mixed-use, healthy communities that that meet the needs of all users of all ages and abilities; support key walking and biking programs and access to public transportation; support Safe Routes to Schools programs; encourage Complete Streets policies; and increase the use of Health Impact Assessments to analyze policies and programs.

* The Baby-Friendly Hospital Initiative (BFHI) is a global program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding. To achieve the Baby-Friendly Designation, facilities must register with Baby-Friendly USA; complete the all of the requirements; and demonstrate that they have correctly integrated all of the “Ten Steps To Successful Breastfeeding” http://babyfriendlyusa.org/eng/index.html.

ASTHO supports outreach and education to inform and prepare providers through:

• The identification of opportunities to assist and advocate for financial incentives for healthcare professionals and institutions such as physicians, nurses, and other clinicians, hospitals, accountable care organizations and insurers, that track body mass index (BMI) and other health indicators, offer evidence-based nutrition and physical activity counseling (including breastfeeding), develop targeted and culturally appropriate interventions, and provide leadership in community-based obesity prevention efforts. 
• State provision of training, educational materials, and technical assistance to communities worksites, and schools interested in offering healthy eating and physical activity programs and policies, especially targeting health disparities and other social determinants of health.

ASTHO supports the evaluation of obesity efforts through:  

• Public health metrics, including vital statistics, hospital discharge data, and health surveillance systems, to track progress of obesity rates in populations, schools, worksites, communities and states and territories.
• Routine collection and use of public health surveillance data, including BRFSS, YRBS, e-codes, and hospital discharge data to identify jurisdictions’ most pressing needs and efficiently target scarce resources.
• Collection of community design data as communities redesign environments to promote physical activity and access to nutritious foods.
• State leadership in the development of robust health information exchange with the clinical sector to improve public health and clinical services.
• Clear benchmark goals and measurement of overall rates of obesity according to the best attainable average level of “goodness” and the smallest feasible differences in obesity rates among individuals and groups or “fairness.”
• Evaluate the feasibility of harmonizing state data collection with HHS data collection on race, ethnicity, sex, primary language and disability status as required by Section 3101 of the Public Health Services Act.

Approval History:

ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Executive Committee. Position Statements are not voted on by the full ASTHO membership.

Prevention Policy Committee Review and Approval on August 10, 2012 
Board of Directors Review and Approval on September 11, 2012 
Policy Expires on September 11, 2015

For further information about this Position Statement, please contact ASTHO Chronic Disease Policy staff at jschneider@astho.org.

Notes

1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and Trends in Obesity Among US Adults, 1999-2008. JAMA. 2010;303(3):235-241.
2. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-2002. JAMA. 2004;291(23):2847-2850.
3. Finkelstein, E. A., J. G. Trogdon, J. W. Cohen, and W. Dietz. 2009. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 28(5):w822-w831.
4. Finkelstein, E. A., J. G. Trogdon, J. W. Cohen, and W. Dietz. 2009. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 28(5):w822-w831.
5. David Thompson, John Edelsberg, Karen L. Kinsey, and Gerry Oster (1998) Estimated Economic Costs of Obesity to U.S. Business. American Journal of Health Promotion: November/December 1998, Vol. 13, No. 2, pp. 120-127.
6. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
7. CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.
8. TA. LaVeist, DJ. Gaskin, P. Richard. The Economic Burden of Health Inequities in the United States. Washington D.C.: Joint Center of Political and Economic Studies; September 2009.
9. National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.
10. IOM (Institute of Medicine). 2012. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press.
11. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.
12. U.S. Department of Health and Human Services, 2008 Physical Activity Guidelines for Americans. Available at http://www.health.gov/paguidelines/pdf/paguide.pdf.