Handbook of Obesity Prevention Shiriki Kumanyika Ross C. Brownson Editors Handbook of Obesity Prevention A Resource for Health Professionals Foreword by Dr. David Satcher Editors Shiriki Kumanyika, PhD, RD, MPH Ross Brownson, PhD Center for Clinical Epidemiology St.Louis University School and Biostatistics of Public Health University of Pennsylvania School 3545 Lafayette Ave of Medicine St.Louis MO, USA 63104 423 Guardian Drive Philadelphia 19104-6021 ISBN-13: 978-0-387-47859-3 e-ISBN-13: 978-0-387-47860-9 Library of Congress Control Number: 2007926434 ©2007 Springer Science(cid:2)Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science(cid:2)Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even ifthey are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper. 9 8 7 6 5 4 3 2 1 springer.com To Christiaan and Chenjerai, who provide strength and inspiration. S.K.K. To Carol, for her support, guidance, and good humor. R.C.B. Foreword In the Surgeon General’s Report: A Surgeon General’s Call to Action to Prevent and Reduce Overweight and Obesity, we referred to the “epidemic” of overweight and obesity. This was an unusual designation for a chronic disease or condition but we felt it quite appropriate. In public health, where “epidemic” has generally referred to an unusual outbreak or increase in incidence of an infectious disease, this application of the term to a chronic condition such as obesity was unusual but appropriate. The increase in overweight and obesity in America over the last two to three decades has been both dramatic and unprecedented and certainly unexpected. We reported that in children over- weight had increased two-fold from 1980 to 2000 and almost tripled in ado- lescents. A similar trend was also seen in adults in America. There was no sign of abatement of this increase as we entered the 21stcentury. Although this dramatic increase in overweight and obesity affected all groups in the nation it impacted some much more than others. African Americans, Hispanics and American Indians were most severely impacted. These were the groups which had been targeted for improvement in health out- comes with the 2010 goal of eliminating disparities in health. But the epidemic of overweight and obesity not only threatens to derail this goal but it also threatens to undue much of the progress in control of chronic diseases that we made in the last half of the 21st century. The concern about overweight and obesity was not about cosmetics and appearances, as we pointed out in the report, it was about health. There are beautiful people who are overweight and obese and there are beautiful people who are thin but this epidemic is about health. The epidemic of overweight and obesity is a threat to our health now and in the future. It was and is a threat to increase morbidity and mortality from diabetes, cardiovascular disease, cancer and osteoarthritis. It interferes with learning in children by increasing risks for asthma and other causes of absenteeism from school and the ability to concentrate in school. It also dra- matically increases costs in the healthcare system. Children who are over- weight, and especially into their adolescent years are most likely to be obese as adults. Thus childhood overweight must be particularly targeted. The cause of this epidemic of overweight and obesity is not altogether clear but it is clear that two major forces in our society have contributed greatly to the epidemic. Those two forces have been the pressures for us to consume vii viii Foreword more calories and at the same time to be less physically active. With the pro- duction and sale of more and more food, the pressure to consume more calo- ries faces us on every corner and with every other commercial. More fast foods have not only meant faster food but also more fat, more sugar and more salt. The other force has been the growing disincentive for us to be physically active. In 1996 the Surgeon General’s Report on Physical Activity was released. As director of the CDC I was involved in the development of that report. We pointed to the dramatic decrease in physical activity by American children and adults. We found, for example, that less than 30% of teenagers were taking physical education in school, and this represented a trend for all students. Physical education was seen as competing with classroom activities geared toward preparing children for standardized exams. Of course we know now that physical activity and good nutrition can improve learning and per- formance by children on math and reading tests, as well as writing. But thetrend to eat more and to be less physically active is not easy to reverse in children or adults. While it is true that treatment is sometimes indicated and possible to deal with obesity, as with other epidemics, it is not the answer to the epidemic. The challenge we face is to prevent overweight and obesity, especially in children but also in adults. In a nation and in a health system where health promotion and disease prevention have never been priorities, except for infectious diseases, we are faced with a daunting challenge to prevent overweight and obesity. Most studies show that we as a nation spend less than two to three percent of our health budget on population based prevention, and population based prevention is what is needed to fight this epidemic. In the language of McKinlay and others this epidemic must be fought, downstream, midstream, and upstream. Downstream we must educate, motivate and mobilize individuals and fam- ilies toward healthy lifestyles that militate against overweight and obesity. As surgeon general I took seriously my designation as “The Nation’s Doctor” and among other things wrote an actual prescription for the American people. On this prescription I encourage physical activity at least 30 minutes a day, five days a week. I also prescribed good nutrition focusing on the consumption of at least five servings of fruits and vegetables per day. The other recommenda- tions related to the avoidance of toxins and being responsible in one’s sexual behavior. Clearly individuals and families must respond to the epidemic by increasing physical activity and consuming a more nutritious, low fat, low calorie diet and becoming significantly more physically active. But this is not enough. We must also act at midstream or in the community where environments can facilitate or militate against healthy lifestyles or eating habits. The school curriculum, the safety of our streets and the general quality of the nat- ural and built environments are critical to allowing and encouraging healthy lifestyles. In the community there must be a commitment especially to cre- ating the kind of environment that encourages children to develop lifetime habits of physical activity and good nutrition. Today children are most sus- ceptible to our “obesogenic” environments, from fast foods to T.V. watching and their related advertisements. Finally, overlooking what individuals can and will be incentivized to do as well as how communities and their institu- tions respond to this epidemic are the local, state and federal policies. This Foreword ix upstream function is critical to our success in stopping and reversing the trend of overweight and obesity. At the end of the Surgeon General’s Call to Action to Prevent and Decrease Overweight in Obesity we listed several settings for action. Among those set- tings we included the home and community, schools, workplace, healthcare, and media/communication. These settings are all very important for attacking the epidemic of overweight and obesity. In many cases they must work together. The program “Action for Healthy Kids,” which we started in the Fall of 2002 and is now nationwide with over 6,000 volunteers, begins by encouraging schools to return to physical education K-12 and to model good nutrition as well as to educate parents, teachers, students and others about the value of physical activity and good nutrition. This strategy is geared toward habituat- ing children to healthy lifestyles in such a way that they will be on the path to good health for life. But this midstream intervention was given new life and a major boost in 2004 when congress passed the Wellness Act (upstream). This act required local school districts that received federal funds for programs such as free breakfast and lunches to put in place policies and programs to help children develop habits of regular physical activity and good nutrition. Already we have seen major movement on the part of school districts to respond to this federal policy. In one program, we are attempting to attack the problem of overweight and obesity at all three levels. This is the 100 Black Men’s Health Challenge started in Atlanta and recently discussed and described in the January issue of the Journal of Health Education. Downstream the program focuses on getting black men to change their lifestyle toward more physical activity and better nutrition. There is close monitoring and group challenge and support for thesechanges. In midstreamthe program takes advantage of the men’s power/ influence in the community and the fact that they often serve as mentors of children from the housing projects. They are in a very good position to work to make the community more supportive of physical activity and good nutri- tion. They can help to make the streets safer and the parks more attractive. Upstream, these men often occupy positions on the school board and even in the legislature and can help to get policies in place that lead to environments which encourage/support healthy lifestyles. Thus the 100 Black Men Health Challenge is a three-dimensional challenge It is especially great to attempt to pull together in one handbook virtually all that we know about the nature and distribution of overweight and obesity and about the various strategies for intervening to prevent and reduce overweight and obesity. Those who are on the front line of the battle against overweight and obesity have come together to put forth the status of our knowledge and experience with the efforts to reverse this dangerous public health trend. This sharing of knowledge and experiences and research strategies is critical if we are to be successful in our efforts. As many new minds and bodies join the efforts against this epidemic they do not need to start from scratch or “reinvent the wheel.” What is already known and experienced in terms of strategies that work and do not work and methodologies that are being applied to further advance knowledge are available in this Handbook of Obesity Prevention. The editors of this handbook are well established and respected for their leadership in public health and especially research related to the nature and x Foreword causes of overweight and obesity and the assessment of strategies for amelio- rating this problem. Thus the book reflects their oversight and the tremendous input of several outstanding investigators and program developers. Dr. David Satcher Director, Center of Excellence on Health Disparities and The Satcher Health Leadership Institute Initiative Poussaint-Satcher-Cosby Chair in Mental Health Morehouse School of Medicine Atlanta, Georgia Preface The statistics are alarming. Over the past decades we have watched the weight levels of the U.S. population shift steadily upward. Media coverage of obesity conveys a continuing sense of crisis—for the population at large, especially children and youth, and for the health care system. We hear threats of spiral- ing health and societal costs related to obesity within the United States as well as dour predictions of the millions affected globally by obesity and its adverse health consequences. It is now clear that the society at large, not just the health sector, has a stake in ensuring that obesity is controlled. So we know that obe- sity must be controlled. The question is how to control it. Without being overly technical, we frame, organize, and explain information relevant to obesity prevention, providing general background and perspective and reviewing how solutions to the problem might proceed within different set- tings or with different audiences. This book attempts to get to the “nuts and bolts” of how to halt and eventually reverse the obesity epidemic. In so doing, we are not starting at the beginning. In fact, the high level of action, energy, and discourse devoted to curbing the obesity epidemic has given us both the moti- vation and mandate for developing this book. Efforts are underway in the pop- ulation at large, in community organizations, in local, state, and federal govern- ment agencies, in voluntary organizations, and within the commercial sector and the media. Some are relatively spontaneous; others have developed more purposely. These efforts encompass a spectrum of initiatives directed both to individual behavior and to aspects of the environments that influence individ- ual behavior. Numerous reports and evidence reviews have been developed. There are national, state, and local action plans that spell out what needs to be done broadly as well as more specific guidelines and tools, while research to build the evidence base is ongoing. Yet, as described in the book, many of the ongoing efforts are not well coordinated and therefore are not obtaining maxi- mum synergy. This book comes at a time when obesity preventionhas emerged as a specific topic within the broader fields of public health, health promotion, and preven- tive medicine—and especially as distinct from the well established clinical and research focus on obesity treatment. In part, we attempt to counter the tenden- cy to talk about obesity “prevention and treatment” while allowing the more familiar, treatment perspective to dominate. Stopping the epidemic means xi